Arrived: The Crisis of Unaccompanied Children at Our Southern Border

Background

Over the past few years, US Customs and Border Protection agents have seen increasing numbers of unaccompanied children and young families crossing into the United States. Most of these young immigrants come from the Central American countries of Guatemala, El Salvador, and Honduras. Contrary to media portrayal, this is not a new issue. These 3 countries are plagued by poverty, complicated by a growing culture of violence bolstered by an illegal drug trade.¹

Although these children have diverse backgrounds, >90% of the children arriving at the border as unaccompanied minors have contact information for a family member living in the United States. Social workers work to contact this person or relative, and if he or she agrees to serve as a “Sponsor,” will conduct a background check of the person. If there are no issues with the background check (which does not include verification of citizenship), the child can be placed with the Sponsor while awaiting a deportation hearing. At this hearing, a child will often be represented by pro bono legal advocates. Some children will qualify for asylum as refugees; others will not, and will be deported. More information about this process is available from the Office of Refugee Resettlement.

Medical and Public Health Issues

Some media sources have argued that the unaccompanied children pose an imminent public health threat, and even some elected officials have asserted that these children threaten our communities. These claims range from the mundane (head lice and scabies) to the exotic (dengue) and much-feared (Ebola).² As pediatricians, it is our responsibility to know the facts, and also to educate our communities about the reality about such health conditions. Although some conditions are serious (eg, tuberculosis), most are not (eg, lice and scabies). Uniformly, they are treatable, and offer the opportunity to improve the quality of life of a child in need. It is important to remember that the illnesses afflicting these children are a reflection of the conditions they experienced in their home countries; the children themselves carry no blame for this.

The number of children who arrived during fiscal year 2014 has outpaced predictions, exceeding 60 000 by the end of August.³ Through the US Department of Health and Human Services, the Administration for Children and Families’ Office of Refugee Resettlement is ensuring the health screening and vaccination of all unaccompanied children placed in their care by Customs and Border Protection. This includes a tuberculosis screen with purified protein derivative (tuberculin) placement and reading (with treatment started for those with active disease), a urine pregnancy test for girls older than age 9, and several key vaccinations according to the Advisory Committee on Immunization Practices catch-up immunization schedule (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed or diphtheria-tetanus-acellular pertussis; meningococcal conjugate vaccine; measles, mumps, rubella; varicella; influenza; pneumococcal conjugate vaccine; inactivated polio vaccine; and hepatitis A and B). More information about the health screening and placement of the unaccompanied children is available from the Office of Refugee Resettlement’s Web site.⁴

The American Academy of Pediatrics has an extensive cadre of physicians who serve immigrant families and have created resources for those who are not as familiar with issues unique to serving immigrant children. Beyond the easily accessible and comprehensive Immigrant Health Toolkit available from the Academy’s Web site,⁵ members of the Immigrant Health Special Interest Group often serve as resources and answer questions about the recent history of immigrant health and policy. These members have organized educational webinars, community meetings, and written responses to both local and national media outlets to both address misinformation and educate communities.

Responsibility of Pediatricians

The question remains: As pediatricians, how can we help these children? Although there is a strong urge from pediatricians across the country to travel to the Rio Grande Valley region to render assistance to these children, this may not be the best use of our skills. The acute phase of this humanitarian crisis is best handled by the expert teams trained in mass migration and public health emergencies. They are screening, vaccinating, and transporting these children to temporary shelters run by the US Department of Health and Human Services, Office of Refugee Resettlement, and their respective grantees.

The reality is that these children do not remain at the border forever. As they are placed with their family members or other sponsors living in communities throughout the United States, the true need is provision of compassionate pediatric primary care in our clinics and emergency rooms. It is at that moment that we all become the “next-responders.” We can build capacity and resilience in our home communities by addressing the needs of these children, as we would do for any child. Our dedication to improving the health of children should not come with stipulations of citizenship status.

To properly care for these children, there are 3 tangible things we can do as pediatricians.

1. Vaccinate. As with any immigrant child, those arriving from Central America will not be eligible for federal assistance programs. They are eligible, however, for local charity care, and for the Centers for Disease Control and Prevention’s Vaccines for Children (VFC) program. As such, providers who participate in the VFC program can anticipate seeing these children in their clinics. If you are not currently a VFC provider or are unable to participate in providing vaccines through the VFC program, consider identifying local participating providers/clinics so that you can refer families to those individuals for care. Helping to identify and outline a vaccine catch-up schedule for these children is essential. Available from the Centers for Disease Control and Prevention, a simple printout of the schedule with a written catch-up plan with “return to clinic windows” added to the vaccine record will streamline subsequent pediatric visits and school enrollment/screening with school nurses.

2. Know your community resources and strengthen existing networks. Begin to identify organizations in your cities and towns that serve Spanish-speaking populations. In addition to clinical care, consider other essential needs, such as telecommunications, access to nutritious food, housing, transportation, religious services, and so forth. Can we connect these children and their families with culturally and linguistically appropriate resources to ensure they have the best possible chance at health? Learn to use the language line at your clinic or hospital or access interpreter services. Obtain copies of key pediatric screening forms in Spanish. The Ages and Stages Questionnaire, for example, is available in Spanish as well as English. As pediatricians, we know that children are resilient. These children have come thousands of miles through extremes of temperatures and terrain, exposed to physical, mental, and emotional trauma. We need to strengthen the mental health linkages that can provide culturally relevant care in our communities. Supporting the integration of mental health care into the primary care setting has the potential to address the trauma that so many of these children have faced along their journey.⁶

3. Advocate. There are countless ways that advocacy can take form in our communities. Medico-legal partnerships can help equip families with resources as they prepare not only for deportation hearings, but also to better understand their rights as immigrants. As providers, we can also task ourselves with gaining a better understanding the rights of these children and their families. We cannot advocate if we are not properly informed. At the end of September, the governor of California signed legislation to provide legal services to the unaccompanied minors arriving in California from Central America. We can advocate for similar legislation to be passed in other states. Last, across the country, community health worker and visiting nurse programs are being heralded as a potential solution to primary care shortages in underserved communities. Urging our local health systems and governments to create and promote such programs in Latino immigrant communities is another way to advocate for these children.