The unique medical school curriculum at MSIH includes a special focus on Global Health. Alumni of the school are trained to work in and research some of the most profound health crises across the globe. The article below is the second in a 3-part series on MSIH Alumni and their experiences with the migrant health crisis at the US-Mexico Border.

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Authors: MSIH Alum Ryan W. Carroll, MD, MPH, and Wallace B. Carroll, MD

Zero Tolerance

The ‘Zero Tolerance’ policy initiated by the US Government in the spring of 2018 resulted in nearly 3000 children being removed from their families as a misguided attempt to deter individuals desperate to seek asylum from violence, extreme poverty, and economic ruin.  Science and history clearly tell us that these children will be irreparably damaged. 

Although the policy has since been reversed, there are reports that the practice continues.  Attempts have been made to reunite families, but for many, these efforts have failed; for those who have reconnected with their families, their interactions are now poisoned by the weeks to months of surviving without their social and emotional support system.  Furthermore, a record number of unaccompanied alien children (UACs) and families with young children are intercepted at the border every month.  For multiple reasons, the processing is taking far longer than anticipated and detained families and UACs are housed in facilities woefully inadequate for the numbers and duration of stay. 

The inexcusable separation of children and the inadequate living conditions defy human rights parameters published decades ago, and places yet another indelible dark mark on the nation’s record of inappropriate treatment of individuals based on their race. 

The Numbers

Violence, conflict, sexual violence, extortion, and hope for a better future have pushed families out of Central America and Mexico, leading to a massive influx of migrants intercepted at the southern border of the US.  At the time of this writing, the number of UACs apprehended by the Customs and Border Patrol (CBP) was 69,157 (July 2019), greater than the total annual number for 2018 (50,038) and 2017 (41,435).  Family Units – the number of individuals apprehended accompanied by a family member – are also rising: 432,838 as of July 2019, far surpassing the annual number for 2018 and 2017, at 107,212 and 75,621, respectively ¹.  First-hand reports highlight the level of desperation faced by these individuals, enough that families travel with children, or more astonishingly, send their children north, risking hypothermia, malnutrition, infection, more violence, and possible death ².

Circumstances have separated children from families, however, the ‘Zero Tolerance’ policy led to the forceful separation of nearly 3000 children from their parents.  There are reports of separation before the start of the policy implementation and growing evidence that children continue to be separated since the cessation of the policy in the summer of 2018.  The total number of children affected may be much greater ^3,4,5 and there is evidence that many are held in facilities well beyond the legal duration, some for over a year ⁶.

The Conditions

Separating children from parents is the most deplorable aspect of this policy, but to add insult to injury, the children are kept in overwhelmingly poor conditions.  A team of physicians and lawyers recently inspected a detention unit in Clint, Texas, noting that children were sleeping on dirty cold floors, suffering from untreated flu and lice infections and malnutrition, and were witnessed providing care for each other – the older children were attending to the younger ones – due to lack of attention from adult personnel ⁷.  By late-May 2019, it was reported that 7 children had died while in the custody of the Customs and Border Protection (CBP), following decades during which no deaths reportedly occurred ⁸.  The UN High Commissioner for Human Rights, Michelle Bachelet, has reacted to the situation, “I am deeply shocked by conditions under which migrants and refugees are held at US detention centres.”⁹.

The Repercussions

Children have responded to being separated by demonstrating posttraumatic stress, anxiety disorders, aggression, and suicidal ideation ¹⁰.  Even after reunification and attempted reintegration into society, children suffer from emotional lability, difficulties in school, behavioral challenges, and nightmares ¹¹.

Previous studies have provided ample evidence that separation leads to long-lasting detrimental psychological and neurobiological effects.  Rodent models of early adversity, including separation from a parent, leads to anxiety-like behaviors, social behavior deficits, hypothalamic-pituitary-axis dysfunction, down-regulation of hippocampal neurogenesis, and a reduction in dendritic branching and synaptogenesis ¹². 

Professor of Pediatrics at Harvard Medical School, Dr. Charles Nelson, has investigated the behavioral and neurobiological changes triggered by the abandonment and separation of children.  In the 1960s, over 170,000 orphaned Romanian children were institutionalized due to a set of draconian laws governing reproduction, leading to a large cohort of children separated from parents.  Not surprisingly, Dr. Nelson’s team found that children in orphanages had lower development and intelligence quotients, which further decreased over time, when compared to children remaining in the care of parents at home ³.  Shockingly, children separated when young demonstrated a reduction in both white and gray brain matter over time, as well ¹³.

In addition to science, unfortunate examples in history provide robust evidence of the detrimental effects of separation.  Bonding, attachment, and subsequent growth are interconnected and require a safe, secure, and consistent environment in which to thrive.  Aboriginal children in Australia who were removed from families were more prone to lives of crime, alcohol abuse, and gambling.  Chinese children who are separated from their parents due to work constraints demonstrated higher rates of depression and anxiety [13].  Survivors of the Holocaust have weighed in on the subject of separation, stating that out of the multitude of atrocities committed by the Nazis, separating children from their parents, by whatever means, was particularly cruel and damaging.  One survivor is quoted saying, “Separation from my [mother and father] was indeed the worst thing that ever happened to me.” ¹⁴. 

Surviving an unimaginably stressful sequence of events in childhood, including witnessing the deaths of friends and family, resulted in long-lasting psychological effects, most certainly compounded by the lack of the protective mental and emotional buffer a parent provides.

Even when good intentions catalyze the decision to send children away from their parents, lasting detrimental effects still manifest.  ‘Operation Pied Piper’ was designed to relocate London children to the countryside at the opening stages of World War II, keeping them safe from air raids and imminent attack, and putatively avoiding the direct physical and psychological traumas of war. In the first year of operation, 3-million children were separated from their parents and relocated.  Evidence demonstrates that separating these children, albeit out of good intentions, led to long-lasting psychological repercussions.  Without their parents to serve as emotional buffers and supports, children suffered greatly on their own, consumed by worry and later, guilt ¹⁵. 

Children can suffer lifelong repercussions even when not removed from parents, but racially-targeted and placed in internment camps.  Half of the 120,000 individuals of Japanese descent remanded to internment camps during World War II were children ¹⁶.  Families suffered from the loss of the concept and the construct of home, the destruction of cultural and familial identity and hierarchy.  Professor Emeritus Satsuki Ina, who was born in an internment camp, has worked with many Japanese-American clients who were interned and found that the trauma has decades later led to depression, strained family relationships, fear of authority, and long-standing sense of undeserved guilt ¹⁷.  Similar research has revealed a greater risk of early death and cardiovascular disease in this population ¹⁸.  The historical data underscores the additive trauma of racial profiling and inhumane detention on children in the midst of their tender stages of development.  

The Response

As early as 2017, the American Academy of Pediatrics (AAP) condemned the practice of separating children from parents on the US-Mexico border.  In 2018, then-president of the AAP, Colleen A. Kraft, MD, MBA, FAAP, stated: “Separating children from their parents contradicts everything we stand for as pediatricians — protecting and promoting children’s health” ¹⁹.  Removing children from families is in direct contravention of Article 9 of the UN’s Convention on the Rights of the Child (1989): “1. States Parties shall ensure that a child shall not be separated from his or her parents against their will, except when competent authorities subject to judicial review determine, in accordance with applicable law and procedures, that such separation is necessary for the best interests of the child. Such determination may be necessary in a particular case such as one involving abuse or neglect of the child by the parents, or one where the parents are living separately, and a decision must be made as to the child’s place of residence.” ²⁰.  Of note, the United States, joined by South Sudan and Somalia, are the only countries to have not ratified the treaty out of the 194 adopting countries ²¹.  As pediatricians, as providers, and as concerned citizens, we too echo the condemnation of the practice. 

Conclusion

This is a humanitarian crisis, with thousands seeking asylum from political persecution, poverty, and violence.  This is a crisis because children have been removed from their families; it is a crisis because thousands more come to the border as UACs and are placed in suboptimal facilities.  Human rights of adults, and more horrifically, of children, are being compromised.  Former Secretary Kofi-Annan is quoted as saying, “Human rights are the expression of those traditions of tolerance in all cultures that are the basis of peace and progress. Human rights, properly understood and justly interpreted, are foreign to no culture and native to all nations. It is the universality of human rights that gives them their strength and endows them with the power to cross any border, climb any wall, defy any force” ²².  This humanitarian crisis will lead to lifelong debilitating psychological and psychophysiological effects for each child involved.  We will not know the full individual and corporate effects of these separations until these children reach adulthood and beyond.   

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References

1. https://www.cbp.gov/newsroom/stats/sw-border-migration
2. Lowenstein, J. (July 2019). “Family, hope and resilience on the migrant trail.” TEDSummit 2019. Retrieved from: https://www.ted.com/talks/jon_lowenstein_family_hope_and_resilience_on_the_migrant_trail#t-834018
3. Santhanam, L. (August 22, 2019). “How detention causes long-term harm to children.”  PBS News Hour. Retrieved from: https://www.pbs.org/newshour/health/how-detention-causes-long-term-harm-to-children
4. Jewett, C. and Luthra, S. (June 28, 2018). “More toddlers appear along in court for deportation under family separation.” PBS News Hour. Retrieved from:  https://www.pbs.org/newshour/health/more-toddlers-appear-alone-in-court-for-deportation-under-family-separation
5. Jordan, M. (July 30, 2019).  “No more family separations, except these 900.”  The New York Times. Retrieved from: https://www.nytimes.com/2019/07/30/us/migrant-family-separations.html
6. “Child separations by the Trump Administration.” (July 2019). A Committee on Oversight and Reform US House of Representatives Staff Report.  Prepared for Chairman Elijah E. Cummings. Retrieved from: https://oversight.house.gov/sites/democrats.oversight.house.gov/files/2019-07-2019.%20Immigrant%20Child%20Separations-%20Staff%20Report.pdf
7. Chotiner, I. (June 22, 2019). “Inside a Texas building where the government is holding immigrant children.” The New Yorker. Retrieved from: https://www.newyorker.com/news/q-and-a/inside-a-texas-building-where-the-government-is-holding-immigrant-children?fbclid=IwAR1MhthdLt1Xz3gfa6StTMo2xbHbjmN8kG02qnPx3lWZHIhBVjRra1CA_sg
8. Acevedo, N. (May 29, 2019). “Why are migrant children dying in U.S. custody?” NBC News. Retrieved from: https://www.nbcnews.com/news/latino/why-are-migrant-children-dying-u-s-custody-n1010316?fbclid=IwAR38n79Vu1jBLejqEPL8NCeCJ7qaGinN2TJOuTfEkVI1BKJDyISX3Jee7Rs
9. Arnold, A. (June 21, 2018). “What to know about the detention centers for immigrant children along the US-Mexico border.” The Cut. Retrieved from: https://www.thecut.com/2018/06/immigrant-children-detention-center-separated-parents.html
10. Teicher MH. Childhood trauma and the enduring consequences of forcibly separating children from parents at the United States border. BMC Medicine 2018. 16;146.
11. Nawaz, A., Frazee, G., and Oh, R. “’Why did you leave me?’ In new testimonies, migrants describe the ‘torment’ of child separation.” PBS News Hour. Retrieved from: https://www.pbs.org/newshour/nation/why-did-you-leave-me-in-new-testimonies-migrants-describe-the-torment-of-child-separation
12. Nelson CA. Can We Develop a Neurobiological Model of Human Social-Emotional Development?  Integrative Thoughts on the Effects of Separation on Parent-Child Interactions. Ann NY Acad Sci 2003; 1008: 48 – 54.
13. Wan, W. (June 18, 2018). “What separation from parents does to children: ‘The effect is catastrophic.’” The Washington Post. Retrieved from: https://www.washingtonpost.com/national/health-science/what-separation-from-parents-does-to-children-the-effect-is-catastrophic/2018/06/18/c00c30ec-732c-11e8-805c-4b67019fcfe4_story.html?noredirect=on&utm_term=.ee7aded9826b
14. Thornton, P. (June 23, 2018). “Holocaust and World War II survivors: Family separation and ‘zero tolerance’ bring back chilling memories.” Los Angeles Times. Retrieved from: https://www.latimes.com/opinion/readersreact/la-ol-le-holocaust-internment-survivors-family-separation-20180623-story.html?_amp=true
15. Wang, A. (June 19, 2018). “What World War II’s ‘Operation Pied Piper’ taught us about the trauma of family separations.” The Washington Post. Retrieved from: https://www.washingtonpost.com/news/retropolis/wp/2018/06/19/what-world-war-iis-operation-pied-piper-taught-us-about-the-trauma-of-family-separations/
16. Ina, S. (1999). “Children of the Camps: Internment History.” WGBH PBS. Retrieved from: https://www.pbs.org/childofcamp/history/
17. Purtill, C. (June 23, 2018). “Japanese-American internment camps taught us what happens to the health of separated families.” Quartz. Retrieved from: https://qz.com/1311736/japanese-american-internment-camps-taught-us-what-happens-to-the-health-of-separated-families/
18. Jensen, G. M. (1998). The experience of injustice: Health consequences of the Japanese American internment. Dissertation Abstracts International Section A: Humanities and Social Sciences, 58(7-A), 2718.
19. Kraft, C. (May 8, 2018). “AAP statement opposing separation of children and parents at the border.”  AAP Press Room. Retrieved from: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/StatementOpposingSeparationofChildrenandParents.aspx
20. “Convention on the Rights of the Child” (November 20, 1989).  General Assembly of the United Nations.  Retrieved from:  https://www.unicef.org/sites/default/files/2019-04/UN-Convention-Rights-Child-text.pdf
21. “25^th Anniversary of the Convention on the Rights of a Child.” (November 17, 2014). Human Rights Watch. Retrieved from:  https://www.hrw.org/news/2014/11/17/25th-anniversary-convention-rights-child
22. Robinson, M. (March 1, 1998). “Welcoming the downtrodden.”  Refugees Magazine (issue 111) UNHCR. Retrieved from: https://www.unhcr.org/en-us/publications/refugeemag/3b80e2a74/refugees-magazine-issue-111-universal-declaration-human-rights-50th-anniversary.html

Suggested readings and references

1. Teicher MH. Childhood trauma and the enduring consequences of forcibly separating children from parents at the United States border. BMC Medicine 2018. 16;146.   A thorough discussion of the separation of children at the border, historic and scientific evidence of its lasting detrimental effects.
2. Linton JM et al., Detention of Immigrant Children. Pediatrics 2017. 139(4): 1 – 13. Prescient in its timing prior to the ‘Zero Tolerance’ policy, this work succinctly and clearly outlines the challenges and repercussions of detaining immigrant children and serves as a policy statement from the AAP. 
3. https://journalistsresource.org/studies/society/public-health/family-separation-child-health-research/ A compilation of readings and references regarding the separation of children, titled, “Family separation: How does it affect children?”  Edited by Denise-Marie Ordway and published on June 27, 2018, by the Harvard Kennedy School Shorenstein Center on Media, Politics and Public Policy. 
4. https://www.ted.com/talks/jon_lowenstein_family_hope_and_resilience_on_the_migrant_trail#t-834018  TED Fellow and journalist for NOOR, Jon Lowenstein gives a riveting exposé of the decade spent following migrant families throughout their journey.  Titled, “Family, hope and resilience on the migrant trail,” this talk was presented at the TEDSummit 2019.
5. https://www.wgbh.org/news/national-news/2018/06/19/experts-weigh-in-on-the-damage-family-separation-inflicts-on-kids  An interview led by Jim Braude with WGBH News Hour on June 19, 2018.   Three experts on the subject are interviewed:  Dr. Jacqueline Bhabha, human rights professor at the Harvard School of Public Health, Harvard Law School and the Kennedy School; Heather Pérez, JD, a legal fellow and detention attorney with the Political Asylum/Immigration Representation (PAIR) Project; and Dr. Louise Ivers, Executive Director of Massachusetts General Hospital’s Center for Global Health and Associate Professor at Harvard Medical School