ESRD in migrants

End Stage Kidney Disease (ESKD) is a serious life-threatening condition in which the kidney is permanently damaged and life-sustaining therapies like dialysis or kidney transplant are needed for survival.1 There are two main treatment routes for ESKD patients: dialysis – which involves the routine aid of artificial kidney machines and kidney transplantation – where a donor’s kidney is transplanted to a recipient.2 Global estimates from 2011 report over 2 million people receive treatment with dialysis or a kidney transplant, and this represents only 10% of the total amount of people in need of treatment.3 In fact, regarding this low access rate, another report estimated that 2.3 to 7.1 million people worldwide with ESKD died due to a lack of access to chronic dialysis.4 In Canada, the number of Canadians being treated for ESKD has more than tripled in the past two decades, with over 40,000 people being treated in 2016 alone.5 Despite the availability of such life-saving treatments for ESKD, access for undocumented immigrants is restricted.6 Undocumented immigrants who are dialysis-dependent are simply denied access to therapies due to their immigration status.7 This article will examine the critical question of whether dialysis-dependent undocumented immigrants should have equal access to health care or denied life-saving treatment based on their immigration status. We argue that health care is a fundamental human right and denying people this right based on their immigration status is inhumane and unjust. Our argument will be presented on the following pillars: healthcare as a fundamental human right, the unethical nature of providing emergency-only care, economic pitfalls of providing dialysis based on immigration status and a rebuttal to the misconception of immigration incentivization via equal health care access. We will explore these pillars by bringing to light the story of an undocumented immigrant with end-stage renal disease. To conceal her identity, we will refer to her as Annie.Story of AnnieA Nurse Practitioner who works in the dialysis unit at a hospital in Toronto recounted a story that reflects the challenges faced by dialysis-dependent undocumented immigrants. Annie is a 25-year-old woman with ESKD who presented at the Emergency Room (ER) with symptoms indicating the need for dialysis. On her first visit to the ER, she told health-care providers that she was visiting Canada as a tourist for a couple of days and had entered the country via the US. Although this account was later unproven, it illustrates the fear of deportation that many undocumented immigrants faced which prevents them from seeking medical care. Based on her account, she was subsequently dialyzed on an emergency-only basis and advised to return to the USA. Four days after discharge, she presented again to the ER with the same symptoms requiring another section of dialysis. A more detailed conversation with her reveals that she was an undocumented immigrant from West Africa. Without a further plan for regular thrice-weekly hemodialysis which is the standard of care for ESKD, she was told that the hospital doesn’t provide regular dialysis spots for undocumented immigrants and she should return to her home country to continue hemodialysis. Pending this return, she will have to pay for each dialysis section she will subsequently need until she returns to her home country in West Africa. She was then given information on hemodialysis centers, with each section costing approximately four hundred Canadian dollars (400cad) and with the required three sections in a week costing one thousand two hundred Canadian dollars (1200cad). When she commented on her financial inability to afford this treatment and the unavailability of hemodialysis in her home country, she was advised to contact an immigration lawyer to seek a compassionate stay. The immigration status of Annie prevented her from receiving the standard care needed for her condition. Week after week, the NP remembered Annie presenting with debilitating symptoms accumulation that could have been avoided with standard chronic hemodialysis. The story of Annie like many other immigrants highlights the health care struggle faced by undocumented immigrants with health conditions needing life-sustaining medical interventions. Health as a fundamental Human rightThe United Nations’ Universal Declaration of human rights recognizes health care as a fundamental human right. This declaration of which Canada is a signatory does not condition health care delivery upon one’s ability to pay, citizenship or immigration status.8 Denying anyone this fundamental human right within Canada’s national border is hypocritical, considering the global image of Canada as a nation that champions human rights around the world. If we as a nation cannot uphold the basic rights of people within our borders, how can we then advocate for the rights of people outside our national border? This deceitful nature of advocating for human rights outside our borders but refusing people such rights within our borders was seen in the now-famous case of Nell Toussaint. Like Annie, Toussaint was an undocumented immigrant who has lived for almost two decades in Canada, working minimum-wage and paying tax while trying to apply for permanent residency.9 While this process was pending due to her inability to pay significant fees, she developed multiple life-threatening medical conditions requiring long term medical services.9 However, due to her immigration status, like Annie, she was denied the needed health care services. With the desire to make a policy change, she submitted her ordeal to the United Nations Human Rights Committee (UNHRC) correctly claiming that her right to life and non-discrimination has been violated. The committee later ruled that Canada violated her right by denying her essential health care and discriminating against her based on her immigration status.9 This ruling affirms that the rights to life and equality of undocumented immigrants like Annie include access to essential health care. Denying such a fundamental human right is nothing but immoral and inhumane.Ethical Dilemma of providing substandard care Narrating the story of Annie, the nurse practitioner high-lighted the ethical issues faced by health care workers when encountering undocumented immigrants. Health care providers are expected by ethical principles to care for the sick regardless of their social, political, religious or immigration status. However, when the level of care is dictated by one’s immigration status this presents a dilemma to a health caregiver who finds themselves unable to uphold the ethical principle of providing the best standard of care to all patients. In the case of Annie, the NP stated that the provision of hemodialysis only during an emergency situation is clearly inferior to the standard thrice-weekly dialysis. This substandard care is associated with 14-times higher mortality rate as compare to those treated with standard dialysis.10 However, because the decision to provide care is made at a policy level, these health care workers are left helpless and continue to provide what they recognized clearly as a substandard care as they struggle to reconcile the ethical principles of justice, beneficence, veracity, and respect for autonomy in a system that limits them to provide inferior care to undocumented immigrants. A study by Cervantes et al (2018) highlighted that clinicians reported experiencing professional burnout and moral distress from feeling compelled to perpetuate injustice and provide inferior care due to immigration status.7 This practice violates medical ethics and prevents health care workers from acting in the best interest of their patients, a difficult moral dilemma. Economic Pitfalls Emergency only hemodialysis as was offered in the case of Annie is associated in addition to high mortality, a substantially higher cost than the standard hemodialysis. The cost of patients receiving emergency-only hemodialysis is nearly four times more than those receiving scheduled chronic dialysis.11 The reasons for this discrepancy lie in the more emergency department visits and hospital admissions as was observed with the story of Annie, who visited the ER on many occasions requiring admissions on a few of those instances. Therefore, the act of limiting standard hemodialysis for undocumented immigrants is more costly over time. Research by Rajeev Raghavan showed that dialysis-dependent undocumented immigrants are younger, have a lower incidence of chronic diseases, have a strong desire to keep working and most of them have a potential kidney donor.12 Annie was just 25 years, a relatively younger age as compared to the older ages of people with ESKD. Addressing the health concerns of this vulnerable group will enhance their ability to return to work and continue contributing to the economic growth of the country. Moreover, living kidney transplantation for young undocumented patients with no major comorbid conditions is economically beneficial to both the society and patients as evidenced from increased life expectancy, ability to return to work, potential growth of the living donor pool and a less expensive alternative to dialysis.12Refuting the misconceptionOpponents who believe that offering dialysis or transplant to undocumented immigrants could incentivize and increased immigration are simply wrong and not based on substantiated evidence. In California where the largest undocumented population of immigrants with ESKD has been provided standard dialysis, there has been no evidence of an increase in its undocumented immigrant population in the last decade.12 Furthermore, studies have shown that most of the undocumented immigrants developed ESRD years after immigrating.13 Therefore, to refuse care on the basis of curbing immigration is a serious misconception. ConclusionImmigrants take on our 3Ds; dirty, dangerous and difficult, injury-prone works, by doing so, they support our future prosperity.14 Most of these undocumented immigrants pay taxes as well while doing these minimum wage jobs, it is, therefore, unjust to deny such a vulnerable population the fundamental human right of health care. It is irrefutable that the provision of standard dialysis to undocumented immigrants with ESKD will improve their medical outcomes, reduce financial costs overtime, support ethical principles and above all uphold the true meaning of universal healthcare. We cannot allow people within our borders to be denied life-sustaining treatment like dialysis. More awareness on the ordeal of this vulnerable population should be made known to the public, this will increase advocacy and awareness, and hopefully, policymakers will understand that borders are man-made and should not be used to define the line between the type of care ESKD patients received.

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