Introduction

Migration status has long been recognized as a determinant of poor health in the USA. Studies from before 2017 found that immigrants faced disproportionately high levels of stress and negative health outcomes, and that stress levels tended to increase as immigrants acculturated to the dominant American society. The Hispanic population experienced the highest levels of acculturation stress [1]. Undocumented immigrants faced even higher levels of stress than documented immigrants, an unsurprising finding given their fear of deportation and decreased access to healthcare and resources [2].

A 2019 report by the Henry J. Kaiser Family Foundation found that among nonelderly adults (ages 18–64), noncitizen-documented immigrants were more than twice as likely than citizens to be uninsured, with 23% of legal immigrants lacking health insurance compared with 8% of US-born and naturalized citizens [3]. Undocumented immigrants were uninsured at approximately five times the rate of citizens, with 45% lacking medical insurance. Undocumented immigrants are ineligible to enroll in Medicaid or purchase health insurance through the marketplace set up by the Affordable Care Act. While undocumented immigrants are similarly excluded from obtaining public insurance through the Children’s Health Insurance Program (CHIP), states are permitted to extend CHIP coverage to the unborn children of undocumented mothers. However, the eligibility for coverage is conferred upon the fetus rather than the mother, so the funds can only be used for pregnancy-related care, not for essential perinatal services such as postpartum care [4].

The picture is not uniformly bleak, however. Some studies have shown that immigrants, especially those from Latin America, have similar or superior health outcomes than native-born individuals with respect to a number of metrics, including fewer low-birthweight infants, lower infant mortality, and better health outcomes later in life [5]. However, these advantages seem to wane the longer an immigrant resides in the USA [5, 6]. While the cause and nature of these so-called health paradoxes have been disputed, recent studies have reported that immigrants in the USA do better in certain areas such as binge-eating or later-life health outcomes [7,8,9].

America’s “Great” Wall

The years since the announcement of Donald Trump’s candidacy for the Presidency of the USA have seen a variety of negative health outcomes for immigrants, both documented and undocumented. From the start of Donald Trump’s campaign in 2015, promises to oppose the entry of undocumented immigrants into the USA and deport those currently in the country formed a central pillar of his policy proposals and messaging. In the speech announcing his candidacy on 16 June 2015, Trump said “the US has become a dumping ground for everybody else's problems.” He further alleged that the government of Mexico was intentionally “sending people that have lots of problems, and they’re bring their problems with [them]. They’re bringing drugs. They’re bringing crime. They’re rapists. And some, I assume, are good people” [10].” After facing criticism from the media and other political figures, Trump doubled down on his allegations that the Mexican government “is forcing their most unwanted people into the United States” [11].

In his announcement speech, Trump also promised, “I will build a great, great wall on our southern border. And I will have Mexico pay for that wall” [10]. The border wall and other immigration-related issues, including a proposed temporary “complete and total shutdown” of the entry of Muslims into the USA following the December 2015 terrorist attack in San Bernardino, California, remained staples of his campaign [12]. Throughout his candidacy and subsequent Presidency, Trump promised to construct a barrier “much higher” than China’s Great Wall; to have Mexico alternately pay directly for the wall or reimburse the American government through tariffs after the fact; and that the cost of construction would first be $4 billion, then $8 billion, and eventually $20 billion [13]. After being elected, Trump continued to use similar rhetoric, arguing that the USA must block the arrival of undocumented immigrants because “our country is full” [14].

After becoming President, Trump spent much of his term fighting with Congress over funding for his border wall [15]. While working to secure money for the wall, President Trump looked at other ways to increase governmental control over the US border with Mexico. The Trump administration has deployed thousands of soldiers to the border to help apprehend migrants [16]. In November 2018, he publicly proposed allowing soldiers stationed at the border to shoot immigrants if they threw rocks at them [17]. After being told this was illegal, he proposed in a White House meeting that soldiers instead shoot migrants in the legs [18, 19]. His administration then announced on 3 September 2019 that $3.6 billion would be appropriated from 127 military construction projects to construct the wall [20]. As of this writing, the administration has not constructed any walls in areas where there were not pre-existing barriers, though they have replaced more than 60 miles of existing barriers with new walls [21]. Barriers already existed along 654 miles of the border, and the administration has begun awarding contracts to construction companies to build new walls [22, 23]. Though construction has yet to officially begin on the wall, the Trump administration has carried out a number of policies that have impacted negatively on the life and health of immigrants, especially new immigrants and those detained for allegedly crossing the border illegally.

A Detention System “on Fire”

Following President Trump’s inauguration in January 2017, his administration directed hundreds of millions of dollars to the Immigration and Customs Enforcement Agency (ICE) to apprehend and detain migrants. As a result, the average daily population of immigrants detained by the USA rose from 34,376 in fiscal year 2016 to 38,106 in FY 2017 to 42,188 in FY 2018 [24•, 25, 26]. Despite an initial drop in the number of border-crossings shortly after the election of President Trump, the following years have seen a sharp rise in the number of border crossings. The resulting increase in apprehensions has placed severe strain on the US immigration system. “The system is on fire,” an anonymous “top official” told The New York Times, describing the inadequacy of existing resources to properly manage and care for the influx of detainees [27]. However, it is not the case that higher border crossings necessitate the record rates of detention that we have seen under the Trump presidency. Monthly crossings on the southern US border are higher in 2019 than at any point since 2006, but they are less than one fifth of what they were in 2000, when over 200,000 migrants crossed the border each month [28]. As seen in Figs. 1 and 2, detentions have risen even as border crossings have fallen.

Fig. 1
figure 1

Average daily population of immigrant detainees [24•, 25, 26]

Full size image
Fig. 2
figure 2

Total undocumented alien apprehensions by Border Patrol [29]

Full size image

President Trump stated on Twitter that detained immigrants “are living far better now than where they [.. .] came from, and in far safer conditions” [30, 31]. However, reports from the detention centers have revealed an overcrowded system that endangers the health of detained adults and children. A surprise inspection in late May 2019 of an El Paso Del Norte Processing Center by the Office of the Inspector General (OIG) found as many as 900 individuals detained in a facility built to house 125 [32]. The report released by the OIG warned that immediate action must be taken to address the “dangerous overcrowding” and described how inspectors found a cell with a maximum capacity of eight holding 41 detainees, a cell with a maximum capacity of 12 holding 76, and another with a capacity of 35 holding 155 individuals [33].

At least 25 migrants have died in ICE custody since President Trump took office [34, 35]. In December of 2018, an ICE supervisor sent a memo to then-Acting Director of ICE Matthew Albence warning that “IHSC [ICE’s Health Service Corps] is severely dysfunctional and unfortunately preventable harm and death to detainees has occurred.” The memo gave several examples of detainees being improperly cared for, including one instance in which an individual who had tested positive for tuberculosis was removed from respiratory isolation, endangering other detainees. “Many detainees have encountered preventable harm and death. IHSC leadership is not focused on preventing horrible recurrences,” the memo states [36]. An independent review by the Human Rights Watch of deaths in ICE custody from December 2015 to April 2018 found that “unreasonable delays in providing care,” “poor practitioner and nursing care,” and “botched emergency responses” contributed to many of these deaths [37••]. The report noted that 12 individuals died in ICE custody in 2017, the highest number of such deaths since 2009. In addition, five children have died in the custody of other US government agencies since President Trump took office [34].

Documents obtained under the Freedom of Information Act by the International Consortium of Investigative Journalists (ICIJ) and the Nonprofit Project on Government Oversight (POGO) found that between 2012 and 2018, thousands of detainees were held in solitary confinement. Furthermore, the number of detainees held in solitary confinement increased significantly following the election of President Trump and the subsequent swell in overall immigrant detention. “International standards established by the U.N. special rapporteur on torture hold that isolation for more than 22 hours a day for more than 15 days in succession constitutes ‘inhuman degrading treatment,’” the ICIJ report notes. Despite ICE agency standards mandating that “a detainee’s stay in isolation must be reviewed at least every seven days,” ICIJ found more than 5100 cases in which detainees were held in solitary confinement for more 15 days; in 573 cases, individuals were held in solitary confinement for more than 90 days [38]. The POGO report, which examined ICE detention records from 2016 to early May 2018, found that approximately 40% of those detainees placed in solitary had a mental illness [39].

Impact on Detained Children

A recent study of the mental health of children held with their mothers in a US immigration detention center found that the children experienced “high levels of mental health distress,” resulting in higher rates of emotional and behavioral difficulties compared with children in the general US population [40••]. Seventeen percent of the 150 children ages 9 and older that they tested using the UCLA Post-traumatic Stress Disorder Reaction Index met all four criteria for PTSD measured by the test: re-experiencing, avoidance, negative alterations in cognition and mood, and increased arousal. Among the general American population, the prevalence of PTSD among adolescents is estimated at 4.7%.

This latest study is only the latest chapter in the large volume of medical research from around the world, indicating that detaining children can lead to trauma, and that adversity in childhood can inflict long-lasting mental health damage that persists well into adulthood [41,42,43,44]. Given the rapidly changing nature of the circumstances of detained migrants in the USA, the literature focusing specifically on those detained since the beginning of the Trump presidency is still being written.

Long before President Trump’s election, the conditions in which migrant children were detained by the US government were dangerous—in February of 2019, Florida Representative Ted Deutch released documents from the Department of Health and Human Services showing that between 2014 and 2018, the government received over 5800 complaints of sexual abuse from unaccompanied minors in custody [45]. A 2018 investigation found that since 2014, the government had paid more than $1.5 billion to contractors operating shelters for immigrant youth that had been accused of “serious lapses in care, including neglect and sexual abuse.” The investigation, carried out by reporters with The Texas Tribune and The Center for Investigative Reporting, found that in “nearly all cases, the federal government has continued to place children with companies even after serious allegations were raised and after state inspectors cited shelters with serious deficiencies” [46].

The magnitude of the problem was greatly enhanced following the Trump administration’s decision in May of 2018 to pursue a “zero-tolerance” policy in which all undocumented immigrants crossing the border would be prosecuted criminally with no exceptions for asylum seekers or children. This decision placed thousands more children into the same system, with disastrous results [47, 48]. Apprehended adults were held in federal criminal facilities where children are not permitted. Prosecuting the adults who arrived with children required separating them and transferring the children to the Department of Health and Human Services’ Office of Refugee Resettlement. From 7 May 2018, when the Department of Justice implemented the zero-tolerance policy, to 20 June 2018, when President Trump signed an executive order requiring the Department of Homeland Security to keep detained families awaiting immigration proceedings together, over 2500 minors were taken from their families or caregivers [48].

At the same time, the government was pursuing its zero-tolerance policy, it was defending itself in court against a lawsuit alleging that children sent to the Shiloh Residential Treatment Center, one of 71 companies contracted with the government to house immigrant minors, were forcibly and regularly given powerful psychotropic drugs [49, 50]. In July 2018, a federal judge ruled that the Shiloh staff had violated child welfare laws and ordered that the government remove all children from the facility, with the exception of children deemed by a licensed professional to be at risk of harming themselves or others [51].

Many families who were separated under the zero-tolerance policy have yet to be reunited. Government lawyers have speculated in documents filed in April 2019 that the process of reuniting all the families could take at least 1 year and potentially 2 [52, 53]. Despite President Trump’s executive order ostensibly ending the practice, as well as a June 2018 ruling by a judge banning the practice except in rare circumstances, the government has continued to separate hundreds of immigrant children from their families [54, 55].

Following the implementation of the zero-tolerance policy, numerous health professionals and organizations spoke out about the negative health effects of the separation of immigrant children from their families. The Society for Research in Child Development released a brief in June 2018 that stated “policies that separate immigrant families upon their entry into the U.S. have devastating and long term developmental consequences for children and their families” [56•]. The American Public Health Association released a statement in November 2018 opposing the separation of immigrant and refugee families, noting that such separations could lead to “fear and traumatization” for children and “extreme grief” for parents [57]. The Young Center, a human rights organization that receives federal funding to advocate for immigrant children in government custody, documented signs of mental harm among migrant children separated from their families, including “cases of children who suddenly lost potty-training skills, forgot their native language, had trouble sleeping or regressed in other ways after being separated from their parents” [54]. In February 2019, Dr. Julie Linton testified to Congress on behalf of the American Academy of Pediatrics that “highly stressful experiences, like family separation, can cause irreparable harm, disrupting a child’s brain architecture and affecting his short- and long-term health.” She noted that such prolonged exposure to extreme stress could lead to long-term mental problems, including developmental delays, learning problems, and depression, as well as chronic conditions such as hypertension and asthma [58•].

A report released in September 2019 by the inspector general of the Health and Human Services Department found that children separated from their parents “exhibited more fear, feelings of abandonment, and post-traumatic stress than did children who were not separated” [59••]. The report further noted that “the level of trauma and unique experiences of separated children made it more difficult to establish therapeutic relationships through which facilities could address children’s mental health needs.” Many children had difficulty distinguishing facility personnel from the immigration agents who separated them from their parents, while other separated children isolated themselves. The report also singled out the hectic and constantly changing process for reunifying separated children with their parents as contributing to the children’s distress.

Impact on Immigrants Across America

Far beyond the detention of those apprehended for allegedly crossing the border illegally, the policies and rhetoric of President Trump and his administration have had a demonstrable negative impact on the health of both documented and undocumented immigrants in America. A study of Latino immigrant attitudes in 2016 found that pervasive negative societal attitudes toward immigrants and political rhetoric had a negative psycho-emotional impact among undocumented immigrants, leading to adverse psychosocial effects such as substance abuse, unprotected sex, and avoidance of medical care or preventative behaviors. Many of those interviewed specifically cited then-candidate Trump’s rhetoric and campaign style as promoting anti-immigrant sentiments and policies that contributed to their feelings of fear and hopelessness [60••]. Similarly, a study published by the Henry J. Kaiser Family Foundation in December of 2017 found that immigrant families were seeking fewer health-care visits due to increased fears of deportation following President Trump’s election [61••]. These included expectant mothers who would greatly benefit from pre-natal care. The study found that increased fear among immigrants extended even to those with lawful status, who described fears of being unable to obtain permanent residence and reluctance to leave the country for fear of being unable to reenter. Both parents and pediatricians told researchers that children of immigrant families were experiencing fear of being deported or losing their parents to deportation, resulting in psychosomatic and mental health issues such as anxiety and panic attacks.

Shortly after President Trump’s inauguration, his administration began discussing changes to existing “public charge” rules that would enable the government to deny applications for green cards (permanent authorizations to live and work in the USA) and visas on the grounds that the applicant would likely become a “public charge,” or someone who is primarily dependent on the government for subsistence. A recent study of food insecurity and participation in the Supplemental Nutrition Assistance Program (SNAP, also known as food stamps) among immigrant families found that “[a]fter steady increases in the prior 10 years, SNAP participation decreased in all immigrant families in 2018, but most markedly in recent immigrants” [62••]. The authors commented that the administration’s proposed rule change could have played a part in this decline. Similarly, in 2018, Politico interviewed more than a dozen providers of the Special Supplemental Nutrition Program for Woman, Children, and Infants (WIC), a federal nutrition program for pregnant women and their children, and found that agencies in 18 states experienced drops in enrollment after news reports on the proposed changes to the public charge rules [63]. Public Health Solutions, the largest WIC provider in New York State, told Politico that it experienced more than six times the normal rate of attrition after initial reports of the proposed rule change. Furthermore, an agency in Longview, Texas explicitly cited immigrants’ fears of being considered a public charge as being behind their loss of 75 to 90 participants in WIC per month. Another 2018 report by AP News found health advocates reporting that the election of President Trump had caused many documented immigrants to stop using health programs and federally subsidized insurance due to fears that their information could be used to deport them or a family member [64]. A May 2019 study published by the Urban Institute found that approximately one in seven adults in immigrant families reported that they or a family member did not apply for or dropped out of a noncash benefit program in 2018 for fear of jeopardizing their chances of obtaining a green card. The study further found that more than this rate became more than one in five for adults in families earning less than 200% of the federal poverty level [65].

In August of 2019, the Trump administration announced the final change to the public charge rules [66]. Under previous administrations, the government did not take into account the receipt of noncash benefits, except to support institutional or long-term care, when evaluating whether an applicant might become a public charge. Under the change implemented by the Trump administration, the definition of public charge was expanded to include recipients of Medicaid, SNAP, or housing subsidies for an aggregate of 12 months within a 3-year period [67]. Over a dozen states filed suit against the implementation of the rule change, as did several immigrant advocacy groups, arguing that the requirements would cause immigrant families to forgo needed benefits and disproportionately hurt poor immigrants while favoring those already wealthy [68, 69]. The rule change was halted by the rulings of three federal judges in early October 2019, but it is likely that the administration will appeal the ruling and attempt to reinstate their policy changes [70].

Future Policies

The Trump administration could take many steps to positively impact the health of immigrants in the USA. Immigrants already contribute more in taxes than they use in public services, so expanding access to governmental health programs such as Medicaid to immigrants, rather than penalizing green card and visa applicants for using noncash benefits, would enable immigrants to be better protected by the system to which they contribute [71]. Reducing detentions for low-risk immigrants, especially families with children, would reduce overcrowding in the government’s detention centers and expose fewer children to potentially traumatic environments.

Instead, the administration appears poised to implement policies that will further harm immigrants’ health, as shown in Table 1. In August 2019, the administration announced it would hold migrant families in detention for the duration of their immigration proceedings, rather than release families in 20 days as was done under previous policy [77]. Though this policy was put on hold by a judge in October 2019, the Trump administration is expected to appeal [78, 79]. Should the policy be enacted, it would result in children being held in detention for months or potentially years [80].

Table 1 Trump administration policies that impact immigrant health
Full size table

The administration’s policies regarding asylum seekers could have a long-lasting impact on those who have come to this country fleeing violence and persecution. A 2016 review of the literature on the impact of detaining asylum seekers in Western countries found that the practice causes harm to mental health not only during detention but also after the detainees are released [81]. Since President Trump’s election, the government has repeatedly attempted to restrict who can apply for asylum. In November 2018, President Trump issued a proclamation that banned immigrants from applying for asylum if they did not come into the country from a legal point of entry. This rule was quickly blocked by a judge, and eventually ruled illegal by a California court [82,83,84]. The Trump administration then announced in July 2019 a new regulation that would bar immigrants from applying for asylum if they passed through another country without applying for protection in that nation [85]. Though an injunction was quickly placed on the new rule, the Supreme Court issued an order in September 2019 enabling the administration to enforce its rule while the legal challenge against it went ahead in court [86]. This will result in more undocumented immigrants’ fleeing violence being detained, with potential long-lasting effects on their mental health.

The Trump administration’s efforts to repeal the Affordable Care Act (ACA), President Barack Obama’s signature health-care reform law, could also impact the health of immigrants in America. The ACA greatly expanded the number of those who were covered by health insurance by expanding Medicaid and applying various reforms to the insurance market [72]. President Trump campaigned on repealing the ACA, and despite the failure of a repeal bill in 2017, his administration has argued that the law should be struck down as unconstitutional [73, 74]. Additionally, the President is reported to be planning to make repealing the ACA a central part of his re-election campaign [75]. The ACA was found in its first 3 years to have significantly reduced the uninsured rates of immigrants (the mean uninsured rate dropped 5.81% for naturalized citizens, 8.23% for noncitizens with less than 5 years of residency, and 9.13% for noncitizens with 5 years or more of residency) [76]. Therefore, a repeal of the legislation has the potential to disproportionately impact the immigrant population of the USA.

Conclusions

The overall impact of President Trump’s policies and rhetoric on the health of immigrants in the USA is clear. Health-care providers should continue to work to educate the public about the adverse impacts of these policy changes. They must also strive to discover and propose new policies and approaches to ensuring the health and safety of all those entering and residing in this land that not so long ago proudly referred to itself as a nation of immigrants.