Sheltering Haitian Humanitarian Parolees in San Diego: A Local Health Department's Response to an International Crisis

A Community and Public Health Partnership

The significant increase of Haitian entrants to the San Ysidro border under the CHEP program initiated a local crisis in San Diego, which was largely a transit point to other areas of the United States for most entrants. Haitians moving to other areas of the country were not eligible for resettlement services while in San Diego, such as health screening, housing, and financial incentives, because they were not residents of the county. The absence of a structured transition plan from the point of entry into the United States to their final destinations lengthened migrants' stay in San Diego and contributed to the accumulation of Haitian arrivals in San Diego. Typically, migrants are responsible for relocating to their final destination once inside the United States, but many Haitians lacked financial resources or were waiting for assistance from family to arrange travel.

The first response to Haitian arrivals was from local faith-based and nongovernmental organizations, which collaborated to provide resources, advocacy, and resettlement or relocation assistance to parolees. Christ United Methodist Church was the focal point for Haitian sheltering, working with other faith-based groups for food preparation and distribution. Through the church, a collaborative response provided for community-centered health services, mobile clinic outreach, immigration advocacy and legal services, and resettlement.

As the sheltering hub, the church quickly became unable to adequately accommodate the growing population of Haitian arrivals. Challenges arose related to food provision and preparation, insufficient sanitation and housing, medical needs, communicable disease prevention, language barriers, and transportation. Requests from these community responders concerning the critical level of the crisis in San Diego resulted in action from the county of San Diego and the state of California.

The role of the county of San Diego was largely one of healthcare and public health coordination and assistance with the benefits eligibility process. The Public Health Services (PHS) Division in the county of San Diego Health and Human Services Agency (HHSA) initiated processes to minimize risk of infection in congregate shelters by assessing shelters, implementing a health screening process in shelters, and providing risk reduction education. Public health nurses assisted with lactation support and education needs of postpartum and pregnant women. Tuberculosis screening, treatment, and isolation for infectious patients and sexually transmitted disease screening and treatment were also services provided by PHS. Tuberculosis was a significant concern, because Haiti has the highest incidence of infection in the Americas (230 per 100,000), ⁵ and the journey from Brazil to the United States contributed to poor health and risk for transmission in congregate settings.

PHS developed a tailored health screening tool and used it to assess for communicable diseases and pregnancy (see Supplemental Material – Screening Tool at http://online.liebertpub.com/doi/suppl/10.1089/hs.2017.0070). This interview-style tool was designed to be administered by trained nonclinical volunteers as part of the shelter intake process, and it was further modified to increase efficacy of use. While tool implementation with Haitians on first arrival remained challenging because of shortages of volunteer staffing and daily new arrivals, several revisions led to a group-administered tool, which helped volunteers to identify symptomatic individuals and women who were pregnant during their arrival orientation at the church for further screening and health services (see Supplemental Material – Self-Screening Tool & Self-Screening Tool Volunteer Guide at http://online.liebertpub.com/doi/suppl/10.1089/hs.2017.0070). Additionally, a self-administered tool in Haitian Creole was made available. Volunteers regularly scanned Haitian arrivals for symptomatic individuals, who were referred for evaluation.

Point-in-time counts were collected by PHS during regular visits to the Christ United Methodist Church and later at 2 armories, with the number peaking at more than 300 individuals sheltered at one time. Case counts of communicable disease were additionally collected through health screening for those resettling in San Diego and other individuals who were relocating. Due to the constant movement of individuals and numerous entities involved in sheltering, resettlement, and health services, numbers of individuals screened and treated proved difficult to precisely reflect. A structured system for capturing and updating arrival and health information would have been beneficial for planning and resource allocation.

The county Department of Environmental Health (DEH) provided sanitation inspections of the facilities providing shelter and preparing food for Haitian arrivals. DEH also placed mosquito traps outside areas of migrant congregation to assess for local Zika transmission risk. HHSA Eligibility Operations staff established temporary offices at shelters to assist with applications for public benefits.

Catholic Charities Diocese of San Diego (CCDSD) was the coordinating agency for local CHEP resettlement, and they assisted Haitian parolees remaining in San Diego with housing, transportation, logistics, and health screening at the preexisting Refugee Health Assessment Program (RHAP). RHAP is a county program contracted through CCDSD and UCSD to ensure health screening of newly arriving refugees, asylum seekers, and CHEP program participants.

As the church-based sheltering became unsustainable, the state coordinated response for Haitian relocation and played a significant role in managing logistics. National guard armories were opened as shelters, and California disaster volunteers assisted with shelter management operations and collaborated with PHS, HHSA Eligibility, and DEH services to provide similar services to those offered in the church. CCDSD worked in the armories to provide logistic and financial support for transit to end destinations. This collaborative effort lasted until changes to the CHEP admission policy on September 21, 2016, disrupted the flow of migrants, eliminating the need to continue large-scale shelter operations. Those remaining were moved to permanent housing in San Diego or provided assistance in reaching final destinations in the United States.

How Was the Haitian Crisis Different?

Lines of jurisdictional responsibility were unclear with the complex dynamics of the Haitian entry process. Immigration is a federal process but affected the local community, so ownership of the situation and response was multifaceted. This created difficulty in establishing a clear incident command structure and impeded communication among federal, state, county, and nongovernmental partners. Provision of mass care and sheltering resources such as facilities, food and water, equipment, and medical care was an ongoing challenge. The situation was not proclaimed a disaster or declared a local public health emergency, as the crisis was humanitarian. While systems are in place for a natural or man-made disaster, neither the county of San Diego nor the state of California has a humanitarian crisis policy or system.^6,7 With no emergency proclaimed, local government was limited in its capacity to access disaster funding and resources through traditional channels that might otherwise have been available. ⁸ Further hindering response was the sensitive political climate regarding immigration during the national 2016 election campaign.

The majority of refugees supported for resettlement in the United States are organized overseas prior to arrival through the International Organization for Migration and the US Department of State in collaboration with resettlement agencies. While CHEP arrivals are not organized prior to their arrival at the US border, the magnitude of Haitian arrivals was significantly larger than had been experienced previously.

Challenges

One of the systems in place in San Diego County is an Emergency Operations Plan that provides a multi-level response for disasters and emergencies, including established relationships and roles between agencies. The recent crisis associated with the Haitian diaspora highlighted gaps in humanitarian and binational policy that influenced the response during a growing emergency.

While there are binational guidelines for US-Mexico coordination on epidemiologic events, policy gaps related to handling humanitarian emergencies and population migration influenced availability of mass care and sheltering resources that are normally provided during other types of emergencies in San Diego County. The absence of transition plans between federal and local agencies from the international border to transitional housing or a final destination compounded the bottleneck of humanitarian parolees in need of shelter in San Diego.

Transportation of parolees between partnering agencies for social and health services and to the airport for travel to a final destination was an ongoing challenge and should be a key goal in future emergency response. Mental health issues were identified as a significant concern in this population after shelter services had been established, given the trauma experienced on the long journey to the United States; attention was given to providing these services toward the end of the program.

Best Practices

A faith-based response model to sheltering can provide significant benefits and has been incorporated into local emergency plans in some jurisdictions. ⁹ Benefits include the ability to respond quickly, provide congregational facilities, and access a network of volunteers. In San Diego, members of an established Haitian ministry were early responders, establishing trust through a cultural familiarity to effectively reach the affected population. Creating a central area for food, shelter, and other resources allowed other nonprofit organizations to coordinate additional services.

Development of a flexible health screening interview tool provided volunteers with the ability to work with PHS staff to modify and implement services with an eye toward cultural sensitivity, thus aiding in its efficacy. This approach helped avoid any communicable disease outbreak during the local congregate living period. Internal collaboration and communication and daily reports between county of San Diego agencies were a major asset in streamlining services and leveraging services with external healthcare partners, while state-sponsored daily meetings with multiple partners helped to mitigate challenges and provided opportunities for sharing responsibilities and resources.

Conclusion and Lessons Learned

Events such as this humanitarian crisis help to identify gaps in infrastructure, resources, and planning. This humanitarian scenario was not previously identified in established emergency protocols, and parameters for emergency declarations in local jurisdictions should be evaluated regularly for opportunities to improve.

Strengthening local Voluntary Organizations Active in Disaster (VOAD) and faith-based networks supports a more resilient community by allowing for a more rapid response. Particularly in border regions, ongoing collaboration and relationship-building with federal and binational partners is beneficial, and this strategy can facilitate early communication and coordinated response. Following any incident, debriefings should include all partners, to discuss response and action items for enhanced preparedness. Maintaining adaptability in public health and emergency systems is a critical component in successful response.