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Expert recounts complexities of immigrant children at border, with call to action

October 10, 2021

Editor’s note: For more coverage of the 2021 AAP National Conference & Exhibition, visit

Images of the unprecedented number of unaccompanied children crossing the U.S. southern border and issues surrounding this crisis have impacted many pediatricians.

Paul H. Wise, M.D., M.P.H., FAAP, described the complex reasons for these developments — and why the issues should be a concern to the pediatric community during his plenary address Sunday “From Kind Sentiment to Action: Improving Care for Immigrant Children at the U.S. Border.”

Professor of child health and society at Stanford University, Dr. Wise also serves as a special expert for the U.S. federal court overseeing the treatment of migrant children.

Most families arrive from Guatemala, Honduras and El Salvador. Drivers of migration include poverty, violence and climate issues such as hurricanes, droughts and crop failures.

“The families and children I’ve spoken with almost always invoke the risk of gang violence as an important motivation to seek refuge in the United States,” Dr. Wise said.

He described the dramatic changes over the years in migrant detention and processing, including the zero tolerance policy.

“The policy criminally prosecuted the parents — sent them to jail, effectively, which turned their children into unaccompanied children and sent them into the Health and Human Services’ (HHS’) shelter system,” Dr. Wise said.

The policy ended after widespread criticism. But many of the more than 7,000 children who were separated from a parent have yet to be reunited with their families, he said.

Then, there was the remain-in-Mexico policy which created large encampments with deplorable humanitarian conditions.

Under the Flores Settlement Agreement, children should be out of Border Patrol custody within 72 hours. Over the past 18 months, however, Border Patrol has had to address the needs of tens of thousands of unaccompanied individuals. The response has been to open emergency intake sites.

The Border Patrol detention system, Dr. Wise added, was built to handle adult Mexican men looking for work but now is being asked to care for unaccompanied children.

Since COVID-19, the U.S. has excluded migrants, most of whom are being sent back to Mexico or flown to their home countries. Many Haitian migrants were returned to Haiti even though they had not been there for several years.

“What I have described is a broken system,” Dr. Wise said.

He outlined the following challenges for pediatrics to address the issues: improving custodial conditions; reforming systems to place unaccompanied children into the care of the HHS Office of Refugee Resettlement instead of having them held by Customs and Border Protection; replacing emergency intake sites with licensed facilities or similar care; and enhancing resources for networks of clinical providers for migrant children released in the U.S.

The mistreatment of children, he said, should never be used as an instrument of immigration policy.

“Once children come into government custody, into the care of the people of the United States, we take care of them…. It is critical that the pediatric community ensure that an improved system is created and implemented with efficiency, attention to the rule of law, but also with justice — requirements that will depend upon leaders like you.”

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