The December 2017 issue of Pediatrics featured the first and second place articles from the First Annual SOPT Advocacy Essay Competition, which focused on the effects and management of toxic stress. The Editorial Board of the SOPT Monthly Feature is pleased to continue this discussion on toxic stress with the following article by Dr Paul E. George. In the article, he poignantly describes the numerous challenges faced by undocumented immigrants and advocates for several key solutions to mitigate the severe effects of toxic stress associated with immigration.

Catherine Spaulding, MD, Editor, Pediatrics, SOPT Monthly Feature

This patient is an adorable 5 y/o F with spina bifida, complicated by paraplegia, bilateral Grade 3 reflux, admitted with a urinary tract infection and infected urachal cyst, status post drain placement, currently on IV antibiotics.

The sign out for Anayansi was perfect. This little girl with giant hazel eyes and curly, black hair, whose lack of English didn’t stop her from talking with anyone in her hospital room, certainly fit the “adorable” description. Yet Anayansi did not garner the most attention on rounds; rather, the gaze of the team members kept drifting toward her mother, or more specifically, toward the conspicuous ankle monitor and charger that confined her to the corner of the room while we discussed her daughter. “I wonder what she did?” whispered my coresident as we left.

A simple question with a bitter answer.

Anayansi’s mother was born outside of the United States. Knowing her daughter would not receive the medical care she needed in her home country, she left with her 2 young children in search of a place where she hoped she could one day give her daughter the chance to walk. Having crossed the US border as an undocumented immigrant, Anayansi’s mother is now considered a criminal. This stressful situation clearly affects her, and consequently, her ability to care for her daughter. Since arriving in the United States, she is sleeping only sporadically, her appetite is gone, and her upper back has started to hurt. Although Anayansi remains gregarious, energetic, and seemingly unfazed, her outward picture may not tell the whole story. Researchers of compelling yet heartbreaking evidence suggest that the toxic stress of undocumented immigration causes significant and lasting physical, mental, and emotional harm. As pediatricians, it is our duty to mitigate the potentially permanent damage these children face by combating the various forms of toxic stress often experienced by immigrant families.1 

Like other undocumented immigrants arriving in the United States, Anayansi and her family received appalling treatment that may have worsened her short- and long-term health. Her family was initially confined to a detention center, known as an hielera, which directly translates to “icebox.” As Anayansi’s mother explained, her family slept on the floor ("el puro piso") in dangerously cold conditions without a mattress or a blanket, requiring Anayansi’s mother to huddle her febrile daughter in her own shirt. This description matches other published accounts and even lawsuits of detainees, who describe children using toilet paper for warmth and women with blue hands and chapped, split lips from the cold.2 At the end of her detention, Anayansi’s mother was given the “choice” of accepting an ankle monitor, which cannot be removed (not to shower or change clothes), must be charged for hours per day, rubs the skin underneath raw, and carries a significant, inescapable stigma, or staying in the detention center while her daughter’s illness worsened.

Although she now lives outside of the detention center, Anayansi’s mother is not free. With tracking from the monitor, she is confined to the city of Houston. She must go to biweekly hearings without a lawyer or other legal counsel. She is despondent about her situation, waiting for the decision on whether her family will be allowed to stay in the United States and whether her daughter can continue her necessary medical treatment.

Authors of literature demonstrate that the stress young children face from having an undocumented parent leads to a myriad of negative consequences,3 such as lower cognitive skills and higher levels of depression and anxiety as adolescents,4 greater likelihood of obesity and substance abuse,5 and increased risk for chronic diseases, ranging from cardiovascular disease6 to asthma7 and cancer.8 On a cellular level, toxic stress is so pervasive that it causes permanent changes in brain function, structure, and even measurable size.9 Optimistically, researchers consistently show that the adverse effects of toxic stress can be mitigated by the presence of a nurturing and protective adult.2 In Anayansi’s case, it is tragic that the person who can best protect her daughter from the ill effects of toxic stress is being treated as a criminal, exacerbating the toxic stress she herself is experiencing.

As a pediatrician, it is unimaginable that we would deny Anayansi or any child access to the benefits of our country, health care or otherwise, simply because they were born on the wrong side of an imaginary line. As an American, it is an insult to our founding values as a nation of immigrants. Ideal medical and mental health management for patients and families like Anayansi’s is complex, involving multiple specialists from both medical and social realms, and at first glance, it might seem overwhelming.

Yet simple steps can be taken to help reduce the toxic stress associated with immigration. A simple mattress and blanket on arrival rather than a cold concrete floor should be provided. There is no benefit of keeping families and children locked in detention centers, not for our national security and certainly not for the children themselves. Ankle monitors, otherwise used for felons on parole, are unnecessarily harsh and stigmatizing for those without criminal records. Every child, regardless of their country of origin, should be provided with the basic human right of health care, not solely because children’s health care is fiscally responsible (which it is given low costs and high preventive benefits10), but because it is the morally correct action. Education regarding the permanent effects of toxic stress on children should be provided not only for pediatricians but also for policymakers, whose decisions regarding an immigrant family’s legal status have significant impacts on child health. Undocumented children need advocates, both locally and nationally, who are willing to fight for these policy changes. We should recognize that people like Anayansi and her mother are the majority of those arriving, not criminals or gang members or people looking to take Americans’ jobs but families escaping “unprecedented violence, abject poverty, and lack of state protection of children and families.”11 

America’s most iconic monument, the Statue of Liberty, has the following inscribed on its base: “‘Give me your tired, your poor,/Your huddled masses yearning to breathe free,/The wretched refuse of your teeming shore./Send these, the homeless, tempest-tost to me,/I lift my lamp beside the golden door!’” Anayansi and her family were literally the poor, the huddled, and the homeless. Seeking refuge at our borders from violence and persecution is not a crime. As fellow human beings, we must insist on higher standards of care for immigrant families and protest against stigmatizing ankle monitors and chilling detention centers. As pediatricians, we must advocate for these children so that their families are treated with empathy and dignity, a first and necessary step toward providing that adorable little girl with curly black hair and thousands like her the healthy childhood they deserve.

The patient’s name and other details have been changed slightly for patient privacy given the sensitive nature of the essay.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.