Editor’s Note: Julie Graves, M.D., MPH, Ph.D., FAAFP is vice-chair for education, Department of Family Medicine at Georgetown University Medical Center. She served as regional medical director for the Texas Department of State Health Services in the Houston area during the health crises caused by the Ebola virus, highly pathogenic avian influenza, Zika virus, and several natural disasters. The views expressed here are solely the author’s. View more opinion articles on CNN.

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This is an open letter to Surgeon General Dr. Jerome Adams on the health crisis faced by hundreds of children, including some infants, whose parents are seeking asylum in the United States.

Julie Graves
PHOTO: Courtesy Julie Graves
Julie Graves

You don’t know me, Dr. Adams, but we have met once, at the National Public Health Week event held this April in Washington, sponsored by the American Public Health Association. You gave a great talk about our responsibilities as physicians working in public health. Now it’s time to discuss your responsibilities as the US surgeon general to respond to this public health emergency.

Though the policy of separating children from asylum-seeking parents at the border has ceased, we learned in a Senate hearing this week that hundreds remain separated, including from parents who have been deported or are elsewhere in the United States. This situation is particularly troubling because some of these children are being housed in facilities in several states that are not suitable for young children. Hundreds of adults are also being held in unsuitable facilities. As they have been shown in the media and described in reporting, some of these facilities are unacceptably crowded. Organizations like RAICES have reported poor conditions and treatment. Photos and video of the tent city in Tornillo, Texas, show people housed in canvas tents. As a native Texan, I know that the climate there would make it difficult to control temperatures in those tents, putting everyone there at risk for heat stroke and heat exhaustion. And everyone in an overcrowded facility faces unacceptable risk of communicable diseases like skin infections, norovirus, and respiratory viruses.

You must insist on and organize adequate medical screening and care for people who seek asylum in this country. You can offer to take charge of and coordinate the public health response. You can pressure HHS and DHS to change their approach, and you can use your moral authority as a physician to speak out, and you can send the expert members of the Commissioned Corps to work with local public health agencies to help these people.

It is clear to me that these facilities lack sufficient public health standards and resources; there are no reports that the FEMA National Incident Management System incident command structure is in place and no adequate medical oversight and intervention in the “shelters” in which these children and adults are being detained. The risk of communicable disease outbreak in what are essentially make-shift prisons is high, as is the risk that undetected medical illness will progress and place these people at risk for serious illness, disability and death. Communicable disease could be transmitted by staff in these crowded facilities into the communities in which these facilities are located.

Since these are mass sheltering events, situations in which large groups of people are in close proximity in small spaces for days to weeks at a time and which are usually seen after a natural disaster like flood or hurricane, as the nation’s lead public health physician it is your job to declare a public health emergency and apply political pressure for public health and medical oversight. By following the Federal Emergency Management Agency Incident Command System, you should order and permit local public health departments to work with local emergency management departments to set up emergency operations centers with mass sheltering oversight that includes medical and public health branches.

FEMA has the ability to respond to both natural and man-made disasters when requested by local or state officials, or when a federal official declares an emergency. You, as surgeon general, lead the National Prevention Council, which provides coordination within the executive branch with respect to prevention, and you oversee the US Public Health Service Commissioned Corps, charged with protecting, promoting and advancing the nation’s health. Because the people who are detained in these facilities as well as the communities around them are at risk for disease outbreaks, you have the responsibility and authority to declare this an emergency and call for FEMA to work with your Commissioned Corps and to coordinate with local public health departments to protect the people being held, as well the public.

Commander Jonathan D. White of the Commissioned Corps told senators on Tuesday that he was unsure whether his department had enough resources to handle large numbers of detained immigrants alone.

In a July 16 statement to the press, an HHS spokesperson said, “Our interpretation of the court’s order is that HHS must make a determination of parentage, fitness, and safety before reunifying families, but that HHS need not undertake the fuller process of vetting for children’s safety that HHS would ordinarily conduct in its operations.” Having reviewed all the news releases on HHS website about this issue, I have seen nothing addressing the suitability of facilities and no response to criticisms of the facilities that have been shown in news photos such as the chain-link fences and the reports of 24-hour lights on situations.

In fact, FEMA has an excellent guide for these mass sheltering events posted on its website. And, after Hurricane Harvey last August, I was a member of the medical team at the Dallas MegaShelter that published our experience sheltering thousands of people at considerable distances from their homes in the journal Disaster Medicine and Public Health Preparedness. You can seek guidance from both these documents.

Texas did a great job after Hurricane Harvey in caring for people displaced into large shelters. Some commissioned corps officers came to the shelters and provided assistance and expertise.

Dr. Adams, you can reach out to the public health leaders in Texas for guidance, and you have experts in the federal government as well whom you can direct to collaborate with local public health departments to ensure adequate medical staffing, resources and support. You can bring your commissioned corps into every one of the facilities holding these children and adults and get the necessary public health interventions and safeguards in place.

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You must get to work today. I’ll help you, as would thousands of US physicians, nurses and public health and other health care professionals. You hold a sacred office and ethical duty to the people of this nation and those who seek help from us, as our surgeon general, our chief physician.

I know you are capable of handling this crisis because during your tenure as Indiana state health commissioner, you led Indiana’s successful response to deal with the largest HIV outbreak related to injection drug use in the history of the state. You are showing passionate and innovative leadership in promoting solutions to the opioid epidemic. Your skills in motivating and education the public and public officials are strong, and your knowledge of public health principles and how to apply them to real-world challenges is evident.

It’s time for you to take immediate action to remedy this current massive public health crisis. Please do it today.