Monday, April 07, 2025


They built a home, a family, a life. Now they must leave for a land they know nothing of

Pakistan has in recent days witnessed hundreds of Afghans dragging their belongings across the Torkham and Chaman borders as the govt began its second drive of deportations on March 31.





Muzhira Amin 
Published April 7, 2025
PRISM/DA

Under an unforgiving Karachi sun, Qari Zaeenuddin and his daughter patiently stand outside Ameen House — a hostel turned detention centre — in the Sultanabad locality. The duo is surrounded by nearly a dozen policemen and their vans guarding the building, where hundreds of Afghans from across the city have been brought of late.

The father, a petite man dressed in a shalwar kameez and white topi, clutches a file close to himself. The girl, whose face is hidden under a naqab, carries a bloated backpack, the weight of which bends her 18-year-old timid back. Both are sweating profusely, but wait silently for their turn. When the station house officer of the area makes an appearance, they rush to him. There is more waiting to do, they are told.

Zaeenuddin, an Afghan refugee, migrated to Pakistan in 1996 when he was just a boy. Initially based in the Hazara division of Khyber Pakhtunkhwa, he later moved to Karachi, where he got married. Bibi Razia, who is accompanying him, too, was born and recently married in the port city. On the third day of Eid, however, her husband was arrested from a naan shop in Banaras, Orangi Town.

“He lost his POR (proof of residency) card, and so they took him,” he says. That day, Zaeenuddin made multiple visits to the area police station before he was told that Kamaluddin had been sent to Ameen House. “I have come here with all the documents,” he points to the file. Inside is Razia Bibi’s neatly stapled POR card, marriage certificate, birth certificate and vaccination cards.

“I have one request: either let him out or take my daughter in too so that they can both go to Afghanistan together … what will she do here alone?” the father cries. “I will wait all day if need be, but I won’t leave until I’m given a definitive answer.” And so Zaeenuddin continues to stand outside the hostel until one of the policemen gives him a seat.


Qari Zaeenuddin and his daughter wait outside Ameen House.


Pakistan has in recent days witnessed hundreds of Afghans dragging their belongings across the Torkham and Chaman borders as the government began its second drive of deportations on March 31, which targeted those holding Afghan Citizen Cards — an identity document jointly issued by the Pakistani and Afghan government in 2017.

The drive is part of a larger campaign that the government began in 2023 to repatriate all illegal foreigners. Under the first phase, all undocumented Afghans were deported, those who didn’t have identity proof.

In Karachi, over the last five days, at least 307 Afghan refugees, particularly those holding an Afghan Citizen Card or ACC, have been sent back to the country their families fled from years ago, according to a provisional police statement available with Dawn.com. Separately, 11,272 Afghans have been repatriated through the Torkham border crossing since April 1.

In 2017, Pakistan, in collaboration with the Afghan government, introduced the ACCs, which were to be issued to those who could not obtain the PoR cards for some reason. The estimated number of ACC holders is around 840,000.

Many of those who crossed the border left behind not only the property, homes and lives they built over the years, but also family members. On the other hand, the ones on this side of the border have found themselves in a constant state of panic and distress.
A tug of war

At an hour’s distance from Ameen House, fear is palpable on the streets of Afghan Basti — a four-decade-old settlement located on the outskirts of Karachi. The road leading up to the camp is almost deserted, the only exception being the honking of loaded trucks.

But deeper inside the safety of the narrow and uneven lanes, the first signs of life appear; young men gathered around a foosball table, children running barefoot, a newly constructed mosque, freshly baked kulchas and the aroma of seekh kebabs.


Kulchas spread out on a table at a naan shop in Karachi’s Afghan Basti.


“Here, we are safe,” says resident and tailor Ibadullah. “Most of us have not stepped outside for almost a week now for fear of being arrested.” A crackdown on the informal settlement a few days back has left him and his neighbours shaken. “Personnel of law enforcement agencies entered our homes and arrested people without even checking their IDs,” he recalls.

A similar incident also took place near the Al-Asif Square at Sohrab Goth on Thursday, a 23-minute drive from the settlement where most Afghan men come for work. Policemen conducted raids and arrests.

“They say we are living here illegally … we were born and raised here, how can we be illegal? These POR (proof of residency) cards were given to us by the government,” Ibadullah says, taking the card out of his pocket. “Why did they issue it to us if we are illegal?”

The POR cards were introduced in collaboration with the United Nations High Commissioner for Refugees (UNHCR) and were issued to over 2.15 million Afghan refugees between 2006 and 2007. These cards were valid for two years, after which they would have to be renewed every two years. Under the programme, the refugees can avail benefits such as opening a bank account, getting jobs and acquiring education.

According to Advocate Moniza Kakar, the government’s deportation deadline for POR holders currently stands at June 30. Kakar is a lawyer and founder member of the Joint Action Committee for Refugees.

He claims that the arrests are money-making tactics. “If you give them (the police) money, they will spare you. If you don’t, they will pack you up and send you to the detention centre,” an angry Ibadullah alleges. “What other option do we have? It is a tug of war between hiding here and getting deported.”

For some, though, the battle is between life and death. Gul Alam, Ibadullah’s neighbour, stands subdued nearby. Lately, he finds it difficult to walk or stand for long. A kidney patient, he has to make weekly trips to the Dr Ruth Pfau Civil Hospital in the city centre for treatment, but it has been two weeks since he left his home.


Ibadullah and other residents of Afghan Basti gather on the streets.



“I have nine children, most of them daughters, what will they do if I am deported?” he frowns. Nearby, a young girl peeks from a stained and hastily sewn curtain draped on the main entrance of the house and brings out a tablet with water for her father. “She does not even know what or where Afghanistan is,” the 55-year-old says.

Most of the residents of the Afghan Basti hold POR cards, which means they aren’t being deported yet. But that does not ease their fear or anxiety. “When they come, they don’t ask for cards, they just use sticks and brute force.

“This has forced so many families to leave the basti and go into hiding,” Alam adds.
From bad to ‘worse’

The raids and crackdowns that Afghan refugees narrate follow a pattern similar to that of 2023, when the deportation campaign first commenced. But Saeed Husain, an anthropologist whose work focuses on Pashtun migration in Karachi, highlights that they have become aggressively worse.

“They are raiding houses and plazas past midnight, and picking up people just based on the suspicion of looking like an Afghan,” he tells Dawn.com. “And once arrested, these people aren’t taken to the magistrate as per due process; instead, they are directly taken to Ameen House and the border from there.”


The entrance of Ameen House in Sultanabad, where Afghans are kept before deportation.

Ameen House was officially designated as an Afghan detention centre in 2023. But Saeed calls it a “black hole” because neither lawyers nor activists are allowed inside. “We don’t know how many Afghans are there, what conditions they are in or how they are treated.

“We also don’t know if the people arrested hold ACC permits or POR cards,” he adds. The Afghans whose family members were taken to the hostel also expressed similar sentiments.

“My nephew is at the detention centre and sent us videos,” an aged resident of Afghan Basti, who wished not to be named, shares. “Around 50-70 people are clamped in a single room, it is extremely hot, and they are being given food only once a day. Hundreds of people are being forced to share a single washroom.”

Dawn.com also visited the tightly guarded Ameen House but was also not allowed inside. The hostel sits next to the Ranger headquarters near Haji Camp. There are hardly any signs that tell it is a detention centre, which Saeed says were there before but have been taken down lately. Only the flurry of activity, most of which takes place at night, signifies that something is happening inside.

According to Deputy Inspector General-South Asad Raza, the hostel is a “bare minimum shelter home that provides lodging and food”. Teams of the National Database and Registration Authority and the Federal Investigation Agency are present at the centre for verification.

“So if in case an Afghan with a POR card is brought, they will be handed back to the respective police station if the Nadra database confirms the same.”


Shops at the Afghan Basti, Sohrab Goth.



DIG Raza further adds that the police did not have any instructions from the government regarding showing high-handedness towards the refugees. Rather, they were given the “task of detaining and deporting those who weren’t leaving voluntarily”.

In case of an arrest, “if any illegal Afghan is arrested, he/she may be presented before the court after being charged under the illegal foreigner act and then sent from jail to the Chaman border for deportation”, he explains.

However, the DIG admits that there were some “handling issues” where Afghan refugees holding POR cards were also detained, leading to scuffles. “But by design, our duty is to repatriate them in a respectful and dignified way.”
To Chaman and beyond

Meanwhile, at the Ameen House, the refugees undergo verification and biometric scans that are conducted by teams of Nadra and FIA. These are used in preparing lists or a “manifest document”, Raza explains. It includes the refugees’ names, IDs, picture, age, gender and the border through which they are set to enter Afghanistan.

Once the document is prepared, the refugees are all filled in buses and taken to the Chaman border via Jacobabad. In the wee hours of Sunday, a convoy of six buses, each with a security in charge on board, departed from Ameen House and headed to the Malir Expressway onto the Karachi-Hyderabad Motorway.


An old man sits outside a shop at Afghan Basti.



Escorted by eight police mobiles, these buses make a stop at a similar detention centre in Jacobabad, from where they head to Chaman, which is at a distance of six hours.

At the border, the “manifest document” is shared with officials from the UNHCR and the Afghan government. For the refugees, those moments are their last in Pakistan, before they enter a country they or their parents were forced to escape.

According to Saeed, who is also a member of the Joint Action Committee for Refugees, once the border is crossed, it is very difficult to maintain contact with those back at home. “Because these people are now looked at with suspicion from authorities on both sides of the border.”

The Taliban government, he continues, has even said that they can’t take in all the refugees. “Where does that leave these people then? You have forced them out of one country and sent them to a place that doesn’t want them.”


Boys play foosball at the Afghan Basti.



UNHCR spokesperson Qaiser Khan also expresses similar concerns in a chat with Dawn.com. “It is imperative that the return of Afghan refugees is voluntary and dignified so that their reintegration in Afghanistan is sustainable,” he says, highlighting that the body is urging Pakistan to look at their situation through a humanitarian lens and calling for engagement between Islamabad and Kabul.

He adds that the agency is also in talks with the government regarding the arrests of Afghan refugees, and lawyers are working on the release of those seeking asylum and POR holders.
Fight till the end

Hundreds of miles from the Chaman border, the residents of Afghan Basti hide their fears, apprehensions, anger and disdain under a veneer of hope. One of them is Ziaul Haq, who runs a general store in the area, atop which the flag of Pakistan is hoisted. The walls of his shop are painted with ‘welcome’ in Urdu.

“My father came to Karachi during the 1980s and he named me after the military dictator at the time,” he gleams with pride. “I named my son Ejazul Haq to continue the tradition.”

He recalls how his father set up the business here at the Afghan Basti and passed away after living a long life. “I was born and raised here … my kids were born and raised here … my parents and grandparents are buried here … my country is Pakistan and none else,” Haq says.


A Pakistan flag hoisted atop a general store at Afghan Basti.



“Jaan jaan Pakistan, dil dil Pakistan,” he chants. “We hope and pray that the government will see our love for this country and give us an identity here.” Soon after, he reaches out to an activist standing nearby and asks: “Sab theek hojayega naa? (Will everything be fine?)”

Haq hasn’t been able to go to the market to restock his supplies since Eid. The reason? Fear, again. “What if they arrest me or demand a bribe?”

The same is the case with several other shopkeepers in the area, who are keeping a trip outside Afghan Basti the last on their list, despite depleting stocks.

But while the men fear, it is 65-year-old Ziabah, who is prepared for everything. She was just 25 when she came to Karachi with her husband and a breast-fed son. “I have spent 40 years of my life here, how can I leave now? And where will I go?” she says, seated cross-legged in her one-room house.

Across from her is a crib where her grandchild coos, an embroidered blanket draped over him. “I don’t remember the name of my village or the people I lived with there … who is waiting for me there?” Ziabah laughs. “Even my language is different now.”


Ziabah, a 65-year-old Afghan woman, sits in a room at her small house.

She is soon joined by her son, Muhammad Rasool, who drives for a livelihood. “I recently visited Afghanistan,” he tells Dawn.com. “Do you know they have a left-hand drive, how will I work there? Even if I lose my job here, I know I will find another. But I don’t know anyone there.”

He takes out his POR card. “This is my identity card, no matter what anyone says,” Rasool asserts. Ziabah, on the other hand, is adamant. “I won’t leave until they forcefully put me in a bus or something,” she says.

Outside her house, children continue to play, almost oblivious to the tense environment around them. One of them wears a green and white cap, adorned with a star.

Header image: Two young Afghan boys walk at the Afghan Basti near Karachi’s Sohrab Goth as a deportation drive is underway in the city. — All photos by 

Afghan return
Published April 7, 2025
DAWN

AS expected, the government of Pakistan is moving ahead with its plan to forcibly repatriate Afghan Citizenship Card holders still residing in the country. It may be recalled that it had earlier announced March 31 as the deadline for ‘voluntary repatriation’, after which stragglers would be deported. By making good on that warning, Islamabad has chosen to ignore repeated calls from humanitarian organisations — including the UN High Commissioner for Refugees, whose representative in Pakistan spoke on Eid to advocate a more compassionate approach and to give refugees more time to return. This decision is the state’s prerogative, and clearly, there’s little anyone else can do about it. As the Foreign Office keenly reminded critics of Islamabad’s Afghan policy around two weeks earlier, Pakistan is not bound by the Refugee Convention, and everything it has done for Afghan refugees has been done ‘out of the goodness of its heart’. Therefore, views like UNHCR Representative Philippa Candler’s, who observed that “Over time, Afghan refugees have become woven into the fabric of Pakistan’s society,” find no currency in Islamabad, where policy hawks have chosen to see Afghans as outsiders and an existential threat.

Now that it has chosen this path, the least the government can do is ensure that all Afghans who are subject to deportation orders are treated humanely and respectfully on their journey back. There is a very strong possibility they will not be, and given their vulnerable status, there are bound to be predators, both state officials and civilians, looking to exploit their situation. The authorities must go out of their way to ensure that deportees’ lives, property and dignity are protected and that they are given ample opportunity to set their affairs in order. Many Afghans came to this country empty-handed. During the time they spent here, some of them have managed to scrape a little of their lives back together. The Pakistani state’s decision to return them to where they fled must not come across as their punishment for being Afghan. If they are being returned ‘home’, as the Pakistani authorities like to frame their decision to deport them, then they must be given reason to feel so. The state can be as firm as it needs to be in order to implement its policy, but it must strive not to do anything cruel. That would help no one.

Published in Dawn, April 7th, 2025

Sunday, April 06, 2025

 

Scientists link a phytoplankton bloom to starving dolphins in Florida



A phytoplankton bloom damaged habitats, deprived bottlenose dolphins of nutritious prey, and led to a sharp rise in strandings and deaths



Frontiers

A deceased stranded dolphin photographed by researchers 

image: 

A deceased stranded dolphin photographed by researchers. Photograph supplied by Hubbs-SeaWorld Research Institute. Stranding response conducted under a Stranding Agreement between HSWRI and NOAA Fisheries.

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Credit: Hubbs-Seaworld Research Institute




In 2013, 8% of the bottlenose dolphins living in Florida’s Indian River Lagoon died. Investigations have now revealed that the dolphins may have starved because key habitats for nutritious prey were destroyed by a phytoplankton bloom. This bloom was driven by the accumulation in the lagoon of fertilizer, effluent from septic tanks, and other by-products of human activity that are rich in nutrients like nitrogen and phosphorus.  

“We linked mortality and malnutrition to a decreased intake of energy following a shift in dolphins’ diets,” said Dr Charles Jacoby of the Florida Flood Hub for Applied Research and Innovation, corresponding author of the article in Frontiers in Marine Science. “We linked the dietary shifts to changes in prey availability, and we connected changes in prey to system-wide reductions in the abundance of seagrass and drifting macroalgae. These reductions were driven by shading from an intense, extensive, and long-lasting bloom of phytoplankton.” 

Signs of trouble 

In 2013, scientists monitoring the Indian River Lagoon noticed that the dolphin population was struggling. 64% of the 337 dolphins they observed were underweight, 5% were emaciated, and 77 died: a toll classified as an unusual mortality event.  

“An unusual mortality event is a stranding event that is unexpected and involves a significant die-off of any marine mammal,” explained Megan Stolen of the Blue World Research Institute, first author of the article. “The 2013 event was characterized by a marked increase in mortality and widespread evidence of malnourishment.” 

Bottlenose dolphins are large, long-lived animals that eat relatively large amounts of many different types of prey, which means that any disruption to the local ecosystem can affect them. In this case, researchers suspected that critical changes were caused by a 2011 phytoplankton bloom that was fueled by nutrient-rich by-products of human activity flowing into, and accumulating in, the lagoon. The bloom shaded bottom-dwelling seagrass and macroalgae in large parts of the lagoon, killing off these key habitats for dolphins’ prey and potentially compromising the dolphins’ ability to hunt. But it’s difficult to prove what dolphins are eating: observations of dolphins feeding at the water’s surface don’t yield a full picture of their diets, and stranded dolphins often have empty stomachs. 

Instead, the researchers focused on isotopic analysis of muscle biopsies collected from stranded dolphins between 1993 and 2013. The ratios of stable isotopes of carbon and nitrogen in muscle from dolphins represent a mixture of similar ratios in their prey, so — using reference values from prey species — the scientists could track dietary changes over time and compare them to contemporary fisheries monitoring and the presence of seagrass and macroalgae.  

Ripple effect 

The scientists found a shift in the dolphins’ diets: during 2011-2013, they ate more sea bream and less ladyfish — a more energy-dense fish associated with seagrass. This agreed with the fisheries monitoring, which recorded changes in the availability of the two species: less ladyfish and more sea bream. It also matched the falling abundance of seagrass and macroalgae habitat over the same period. The shift from ladyfish to sea bream meant that dolphins would need to eat about 15% more prey to acquire the same amount of energy. 

“In combination, the shift in diets and the widespread presence of malnourishment suggest that dolphins were struggling to catch enough prey of any type,” said Wendy Noke Durden of Hubbs-SeaWorld Research Institute, a co-author. “The loss of key structural habitats may have reduced overall foraging success by causing changes in the abundance and distribution of prey.” 

The data also tallied with causes of death recorded for stranded dolphins. Between 2000 and 2020, malnutrition caused 17% of all recorded deaths, but in 2013, this figure rose to 61%. 

“All studies have their limitations,” cautioned co-author Dr Graham Worthy of the University of Central Florida. “We did not have data on ratios of stable isotopes in all the prey that dolphins were eating from 1993 to 1999, so we could not fully explain the shift in diets observed from that early period to 2000–2010. Additionally, the link between malnourishment and a change in diet would have been enhanced by stable isotope data from the muscle of surviving dolphins.” 

“Blooms of phytoplankton are part of productive ecological systems,” said Jacoby. “Detrimental effects arise when the quantities of nutrients entering a system fuel unusually intense, widespread, or long-lasting blooms. In most cases, people’s activities drive these excess loads. Managing our activities to keep nutrients at a safe level is key to preventing blooms that disrupt ecological systems.”  


 

Local access to abortion services expanded with mifepristone in community pharmacies



Canadian Medical Association Journal





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Before 2017, abortions were generally performed as procedures in fewer than 100 hospitals and clinics mostly in urban centres, leading to delayed care, particularly for people living in rural areas. Medication abortions, mainly via off-label use of methotrexate, were infrequent.

Researchers looked at population data from ICES to examine abortion service availability changes in Ontario from January 2017 to December 2022. Between 2017 and 2022, there were more than 226 000 abortions provided to 175 091 people. The proportion of regions with a pharmacy that dispensed mifepristone increased from 20% in 2017 to 82% in 2022. Only 37% of abortion service users lived in a region with either a mifepristone-dispensing pharmacy or procedural provider in 2017, but this increased to 91% by 2022.

Access to abortion services increased in both urban and rural areas.

“Despite these rapid gains in access to procedural or medication abortion services, in 2022, 6% of regions had no pharmacy at all, nearly 20% of regions with a pharmacy still lacked a pharmacy that dispensed mifepristone, and roughly 9% of abortion service users lived in a region without a local procedural provider or a pharmacy that dispensed mifepristone,” writes Dr. Laura Schummers, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, with coauthors.

The authors note that the expansion of mifepristone to community pharmacies shifted the delivery of abortions from procedural abortions to more accessible mifepristone abortions, a trend they expect to continue.

“Abortion service needs are time-sensitive, as risks of abortion complications increase exponentially with increasing gestational age. It is likely that the proportion of abortions provided by medication in Ontario will continue to increase beyond our study period, mirroring trends elsewhere.”

“Changes in local access to mifepristone dispensed by community pharmacies for medication abortion in Ontario: a population-based repeated cross-sectional cohort study” is published April 7, 2025.

Media contact: Media relations, ICES, media@ices.on.ca

General media contact: Kim Barnhardt, CMAJkim.barnhardt@cmaj.ca

Please credit CMAJ, not the Canadian Medical Association (CMA). CMAJ is an independent medical journal; views expressed do not necessarily reflect those of its owner, CMA Impact Inc., a CMA company, or CMA.

 

Dietary shift after migration increases cardiovascular risk by altering the composition of an individual's gut microbiome



Amsterdam University Medical Center





An Amsterdam UMC-led study has found that migrants, this case from West Africa to Europe, experience a ‘clear change’ in their microbiome composition as compared to their non-migrant peers in West Africa, which expose them to an increase of cardiovascular disease. These peer-reviewed findings are published today in the journal Gut Microbes demonstrating that participants who lost specific groups of microbes or acquired specific new groups of microbes had higher rates of cardiovascular risk factors such as hypertension, diabetes, obesity, and poor kidney function. 

“The results clearly demonstrate the importance of our findings in the relation to migration-related health outcomes,” explains postdoctoral researcher at Amsterdam UMC and first author of the study, Barbara Verhaar, who carried out the research together with colleagues at the University of Ghana, and Kwame Nkrumah University of Science & Technology (KNUST). 

"It was already thought that migration had an effect on an individual's microbiome, but previous studies have either lacked in the number of individuals included, didn't control for variations in diet or only compared first- and second-generation migrants. Our study makes use of our own RODAM study cohort to definitively demonstrate this change,” says Verhaar.  

The Amsterdam UMC led study included more than 1100 individuals from two separate continents and three locations: rural Ghana, urban Ghana or Netherlands. Respondents completed identical dietary questionnaires and provided both fecal and blood samples to determine the composition of their gut microbiomes. Analyses revealed the presence of different microbes across the three groups, in line with the hypothesis that migration would affect microbiome composition. The findings show that some groups of microbes disappear, and new ones emerge along the migration axis. 

Health Outcomes 

Previous studies, as well as the World Health Organisation, note that migrants frequently experience poorer health outcomes than native residents and research from Amsterdam UMC has found this also to be the case in the Netherlands.  

"This research underscores the relevance of gut health and how we look at the adverse health outcomes that are often associated with migration. It is fascinating to learn that when we migrate, we lose some relevant microbes we acquired in our home countries and pick up new microbes in the new countries, and this can influence our health very importantly. We found that macronutrient groups such as protein, fat and salt in food were strongest associated with gut microbiota composition and these were higher in migrants, which might have contributed to the shift in gut microbiota composition. Future longitudinal studies are needed to verify these findings,” adds Charles Agyemang, Professor of Global Migration, Ethnicity & Health at Amsterdam UMC and senior author of the study. 

Cardiometabolic risk is a growing concern for researchers across the globe and Agyemang is currently leading a host of projects, both in the Netherlands and several African countries, that aim to develop better interventions to lower the risk of developing cardiometabolic diseases, such as diabetes and hypertension; and to improve management of cardiometabolic diseases.  

As part of these efforts, as in this study, he works with the several institutions across the globe especially in the African region to ensure that research in Amsterdam is strengthened with international data and, also, that research findings are translated into concrete policy.  

"The findings of this study provide important insights into how migration can reshape our gut microbiota and subsequent health outcomes and emphasizes the needs for north-south collaborations,” adds Ellis Owusu-Dabo, Professor of Epidemiology and Global Health, KNUST.  

 

Viability of hospital-based emergency care in US faces peril


Report finds that reforms needed to boost payments, support workers




RAND Corporation




The viability of hospital-based emergency care in the U.S. is at risk, threatened by issues such as patients with increasingly complex needs and falling payments for physicians, according to a new RAND report.

Many of the problems facing emergency medicine are expanding in scale, including long emergency department wait times, boarding patients in emergency department beds and a high amount of uncompensated care. 

The issues are in focus as the use of hospital emergency departments return to levels seen before restrictions prompted by the COVID-19 pandemic limited use of emergency departments, according to researchers.

“Urgent action is needed to sustain hospital emergency departments, which act as a safeguard for patients who use the services and communities that rely on them during a crisis,” said Mahshid Abir, the report’s lead author and a senior physician policy researcher at RAND, a nonprofit research organization. “Unless these challenges are addressed, there is an increasing risk that emergency departments will close, more doctors and nurses will leave emergency medicine, and patients will face even longer waits for care.”

Researchers say a key problem facing hospital-based emergency medicine is that many of the services provided are not directly reimbursed by public or private payors. 

Under federal law, all people who arrive at emergency departments must be assessed and stabilized, regardless of their ability to pay. In addition, activities such as coordination for follow-up care, responding to mass casualty incidents and preparing for public health emergencies are not directly reimbursed. 

RAND researchers recommend a new, tiered payment model that would build upon the existing payment system to address those shortcomings. 
The recommendations include new payments from public and private payors to emergency health care professionals for the public health services not already covered by insurance, such as mental health and infectious disease screening. 
Researchers also recommend expanding Medicaid payments directed to hospitals that care for large numbers of uninsured patients and increasing payments from public insurance programs to reduce the gap between private and public reimbursements. 
Hospital-based emergency departments have been at the forefront of responding to the opioid and gun violence epidemics, and played a critical role in providing care throughout the COVID-19 pandemic. 

Nationally, hospital emergency departments handle 120 to 140 million visits each year, compared with about 1 billion physician office visits annually. The number of hospital emergency departments is declining, with most closures occurring in rural areas.

The RAND study found that the scope of work for emergency physicians in the U.S. health system is expanding, with evidence that emergency departments have become hubs that offer various services beyond emergency care. This expanded focus includes inpatient observation care, hospital-at-home and remote patient-monitoring programs, and emergency department critical care units.

Researchers found that Medicare and Medicaid payments to emergency department physicians fell 3.8% from 2018 to 2022. Reductions in payments for commercially insured patient visits were much steeper, dropping 10.9% for commercial in-network and 48% for commercial out-of-network visits over the period.

The RAND report is based on interviews and focus groups with emergency medicine professionals, a survey of more than 200 emergency medicine department leaders, case studies, a review of other published research, and analysis of administrative data. The study was overseen by a 13-member advisory board that included emergency medicine professionals, emergency care policy experts and other health care experts. 

Support for the project was provided by the Emergency Medicine Policy Institute.

The report, “Strategies for Sustaining Emergency Care in the United States,” is available at www.rand.org. Other authors of the report are Brian Briscombe, Carl T. Berdahl, Kirstin W. Scott, Sydney Cortner, Daniel Wang, Rose Kerber and Wilson Nham.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.