Health Repercussions of a Culture of Fear Within Undocumented Immigrant Communities

Immigration status is an increasingly relevant social determinant of health that has detrimental implications for the health, safety, and well-being of the roughly 11 million undocumented immigrants living in the USA.^1–3 The ability and willingness of this marginalized population to seek healthcare is often affected by cost, language, and knowledge of the healthcare system. Additionally limiting is fear of discrimination and deportation exacerbated by anti-immigrant rhetoric and policies that permeate immigrant communities with a culture of fear.^{4, 5} This culture of fear has a negative impact on patient’s mental and physical health, and contributes to patients delaying or avoiding care.^{6, 7}

Over the last decade, the US Government’s focus on border security, processing of undocumented immigrants, and deportation has contributed to a culture of fear within undocumented communities. During the Obama administration, deportation of undocumented immigrants increased substantially.⁸ The Trump administration has additionally targeted undocumented immigrants through memorandums, appointments, and changes in policy. On September 5, 2017, the Trump administration announced it would end the Deferred Action for Childhood Arrivals (DACA) program, excluding 800,000 youth and young adults from the opportunity to legally work and obtain higher education in the USA.⁹ It is still unclear how DACA will be reformed or dismantled, but what is clear is that efforts such as these will have lasting implications within undocumented communities. In addition, on October 17, 2017, Thomas Homan, the former director of Immigrations and Customs Enforcement (ICE), announced he planned to “quintuple” worksite enforcement actions.¹⁰ This statement foreshadowed coordinated sweeps of 98 Seven-Eleven stores across 17 states to deport undocumented employees on January 10, 2018. Perhaps the most frightening example of the interplay between ICE and undocumented communities is the case of Rosamaria Hernandez, a 10-year-old child with cerebral palsy who was detained as she was being transported via ambulance between hospitals for emergency surgery.¹¹

Poor access to medical care is one of many forms of health discrimination that undocumented immigrants face, which leads to poor healthcare outcomes and lower quality of life.¹² For instance, excluding undocumented immigrants from healthcare has been found to lead to small increases in the incidence of infectious diseases.¹³ Fear of immigration enforcement has also been identified as a reason patients with tuberculosis delay seeking care, which threatens both individual and public health.¹⁴ Furthermore, undocumented immigrants with end-stage kidney disease who were dependent on emergent dialysis due to their immigration status were found to have high rates of unexpected death due to cardiac arrhythmias.¹⁵ Findings such as these have led the American Public Health Association to recognize exclusionary immigration policies as harmful to undocumented immigrants’ health.^{16, 17}

There has long been concern regarding the treatment of undocumented immigrants during the deportation process. Recent media coverage of the separation of immigrant families has increased public awareness about the severity of the issue. Separating children from their parents clearly places them under toxic stress which has been proven to have a detrimental impact on brain development and increase the risk of post-traumatic stress disorder.¹² A 2018 study found that immigrant children separated from their parents had significantly higher risk of emotional and behavioral problems as well as lower literacy rates.¹⁸ Children and adolescents who are exposed to toxic stress suffer from life-long mental health illness, impaired ability to learn, poor adaptive behaviors, and decreased adult productivity.¹⁹ We thus surmise that children raised in a culture of fear due to immigration status are likely to experience toxic stress with enduring effects on their mental, emotional, and physical wellbeing.

Exclusionary tactics and policies aim to reduce undocumented immigrants access to healthcare and social services. These practices have been shown to be deleterious to the health of undocumented immigrants and result in increased health costs.^{20, 21} Provision of healthcare to immigrants is often met with concern for over-utilization of healthcare resources and excessive cost. However, undocumented immigrants tend to use the healthcare system less and have lower associated health costs than native citizens in the USA.^{22, 23} In contrast, inclusive policies such as DACA that worked to incorporate long-standing undocumented residents into society led to improved self-perception of health, utilization of social services, and access to physicians/mental health professionals.^{24, 25} Furthermore, Sweden’s health policy which provides a range of care to undocumented immigrants has cost much less than predicted.²⁶

The USA frequently offers undocumented immigrants economic advantage, sanctuary from violence, and improved quality of healthcare than offered in native countries. Unfortunately, once undocumented immigrants are in court, they are often deported even if they are lawfully in the USA. The importance of representation is immense as immigrants with attorneys present for their proceedings were four times more likely to be released from detention and twice as likely to obtain the immigration relief they sought.²⁷ By partnering with and distributing information for reputable legal advocacy organizations, healthcare providers can help prevent patients from being deported and falling victim to immigration law fraud. Identifying a licensed attorney who specializes in and practices immigration law is ideal as immigration law is extremely complex and frequently changes. While a specialized attorney is preferred, there are unfortunately few attorneys who specialize in immigration law and cost is often prohibitive. Physicians should also know immigration law fraud is unfortunately common and can have devastating consequences involving financial strain, delayed application for citizenship, declined applications, and/or deportation.²⁸ To assist patients who may encounter immigration authorities, physicians can provide cards generated by the National Immigration Law Center entitled “Know Your Rights” that outline protected civil liberties; immigrants can hand these cards to immigration officials if they are detained.

Healthcare providers are under no legal obligation to inquire into or report immigration status to authorities. This argument stems from the first amendment which protects the right to free speech but also the right to not speak. Physicians are mandated reporters in some circumstances such as child or elder-abuse; however, reporting undocumented immigrants is not an obligation and could violate the Health Insurance Portability and Accountability Act (1996).²⁹ Furthermore, healthcare professionals are encouraged not to inquire about patients’ immigration status and are discouraged from including that information in patients’ medical record or billing information.³⁰ Lastly, Immigrations and Customs Enforcement (ICE) as well as Customs and Border Patrol (CBP) have both issued memoranda that consider clinics and hospitals to be “sensitive locations,” where immigration enforcement is to be avoided unless officers have obtained official approval.³¹

In summary, undocumented immigrants suffer poor health outcomes, particularly regarding mental health, with life-long consequences. It is imperative that physicians recognize the barriers to care undocumented immigrants face and help by protecting their immigration status, identifying immigration attorneys in the area, and distributing “Know Your Rights” materials. Lastly, providing compassionate care with an informed understanding of the social, legal, and economic barriers undocumented immigrants encounter will combat the culture of fear and improve the health of this vulnerable population.

Compliance with Ethical Standards

Conflict of Interest

The authors have no conflicts of interest to disclose.