Like many health conditions that disproportionately impact vulnerable populations of color, we expect that the coronavirus disease (COVID-19) pandemic will inequitably affect the health and livelihoods of immigrant families. One in 4 children (>18 million) in the United States lives in an immigrant family, in which the child or ≥1 parent was born outside the United States.1  Among children in immigrant families (CIF), >7 million live in “mixed-status” families, meaning ≥1 parent is not a US citizen.2  Before the COVID-19 pandemic, immigrant families faced increasingly restrictive policies and discrimination. Regardless of legal status, CIF experience increased health and social risks compared with peers in nonimmigrant families, including lower rates of health insurance coverage and higher poverty levels.3  The COVID-19 pandemic amplifies existing inequities and introduces new ones as immigrant families navigate school closures, lack of health insurance and paid leave, and decisions to seek medical care or public services amid ongoing immigration enforcement. Additionally, immigrant families are more likely to live in multigenerational households,4  heightening the risk of COVID-19 for multiple family members. Families with limited English proficiency (LEP) must decipher rapidly evolving public health directives, such as “shelter-in-place” orders and recommendations for mask-wearing, without multilingual and culturally relevant messaging.

Underlying these challenges is the implicit presumption of a safe place in shelter-in-place and social distancing directives. For immigrant families seeking safe haven in the United States, “place” may include violence and abject poverty, both in home countries and at the US border. For CIF in US communities coping with persistent fears of immigration enforcement and family separation, economic devastation during a pandemic may threaten the stability of place. In this article, we apply a health equity framework5  to evaluate the impact of COVID-19 on CIF and highlight opportunities for advocacy and action for pediatricians, hospitals and health care systems, and policymakers to mitigate the unique risks faced by CIF (Table 1).

TABLE 1

Potential Strategies To Address Challenges Due to COVID-19 for CIF

Strategies
For pediatricians  
 Health care access and delivery Highlight opportunities to celebrate the strengths of immigrant families despite fear and uncertainty, including cultural pride reinforcement6  and reading multilingual books7  together.  
Share multilingual information8  with families regarding COVID-19, including social distancing,9  wearing masks in public,10  and testing for COVID-19.  
Provide information on free health clinics11  and/or local health resources for mixed-status families.  
Offer resources for families to cope with emotional distress associated with COVID-19, such as strategies to manage stress and anxiety,12  talking with children about COVID-19,13  and disaster support.14  
Encourage employers to implement telemedicine15  systems that support the needs of immigrant families, including dissemination of information in preferred language and availability of interpretation. 
 Socioeconomic impacts Emphasize comprehensive screening for social determinants of health.16  
Encourage participation in public programs (eg, Medicaid, WIC, SNAP) for which children and families are eligible.17   
Provide resources to mitigate food insecurity, including school-based nutrition programs18  and food banks.19  
Refer families to community-organized, culturally and linguistically relevant, updated SDH resource links (eg, Hispanic Alliance, Greenville, SC20 ; Informed Immigrant Resources21 ; Immigrants Rising22 ; Aunt Bertha23 ). 
 Immigration enforcement and policy Acknowledge fear and uncertainty that families are facing and offer resources, including Know Your Rights materials.24  
Familiarize yourself with legal resources for immigrant families25  who face particular risks for lack of access to public services or immigration enforcement. 
For hospitals and health care systems  
 Health care access and delivery Ensure that free testing for COVID-19 is accessible and advertised to immigrant families.  
Develop and implement free walk-up and drive-through testing and treatment (eg, New York City, NY26 ; Trenton, NJ27 ) sites within trusted venues in immigrant communities, such as schools, community centers, or places of worship. 
Increase capacity for access to interpreters and patient navigators to facilitate telehealth. 
Rapidly employ and train bicultural, bilingual professionals and paraprofessionals (eg, community health workers28 ) to assist with COVID-19 testing and information dissemination in densely populated immigrant communities. 
 Socioeconomic impacts Implement and/or expand systems-wide screening for social determinants of health in the setting of COVID-19.29  
Ensure continued access to social workers, community health workers, and other team members dedicated to connecting families to resources such as unemployment, nutrition, housing, and other public and community-based programs. 
 Immigration enforcement and policy Post welcoming signage30  that offers families a sense of safety while seeking health care services.  
Ensure that any security presence during visitor and patient screening protocols is trained to offer culturally relevant, sensitive screening that recognizes disparate impact of law enforcement on communities of color, including immigrant families.  
Develop protocols that ensure the rights of immigrant families are maintained31  while seeking health care. 
For policymakers and public health entities  
 Health care access and delivery Develop and disseminate smartphone-accessible resources32  and materials in multiple languages.  
Clarify access to free testing and treatment regardless of immigration status (eg, New York City33 ).  
Encourage states to provide Medicaid to all individuals regardless of immigration status, including those with DACA, TPS holders, green card holders, and undocumented individuals, to ensure that they have access to testing and treatment.  
Ensure access to data stratified by race, ethnicity,34  and language preference to better implement interventions that meet the needs of communities who are most impacted. 
Suspend public charge enforcement. 
 Socioeconomic impacts Ensure that resources on public websites about COVID-19 include accessible, multilingual information regarding access to housing, food, and other critical services (eg, Chicago, IL35 ; Boston, MA36 ).  
Include all immigrants, regardless of legal status, in any federal or state financial relief package (Chicago, IL37 ). 
Expand unemployment eligibility to people with DACA and TPS and to others who have work eligibility. 
Automatically extend work permits for individuals with DACA, TPS, and nonimmigrant visas for the same time period as the individual’s status or work authorization. 
Place a moratorium on housing evictions and foreclosures,38  utilities termination,39  and suspended telephone or Internet services.40  
 Immigration enforcement and policy Develop timely and well-communicated protocols for immigrants in ICE custody who fall ill, and immediately close the 3 family detention facilities, ensuring monitoring for symptoms with community-based case management.  
Resume access to humanitarian protection at the US–Mexico border for unaccompanied children and family units.  
Stop interior ICE enforcement unless someone has a criminal background that threatens public safety. 
Continue DACA renewals, including work authorization, and resume acceptance of new applications. 
Strategies
For pediatricians  
 Health care access and delivery Highlight opportunities to celebrate the strengths of immigrant families despite fear and uncertainty, including cultural pride reinforcement6  and reading multilingual books7  together.  
Share multilingual information8  with families regarding COVID-19, including social distancing,9  wearing masks in public,10  and testing for COVID-19.  
Provide information on free health clinics11  and/or local health resources for mixed-status families.  
Offer resources for families to cope with emotional distress associated with COVID-19, such as strategies to manage stress and anxiety,12  talking with children about COVID-19,13  and disaster support.14  
Encourage employers to implement telemedicine15  systems that support the needs of immigrant families, including dissemination of information in preferred language and availability of interpretation. 
 Socioeconomic impacts Emphasize comprehensive screening for social determinants of health.16  
Encourage participation in public programs (eg, Medicaid, WIC, SNAP) for which children and families are eligible.17   
Provide resources to mitigate food insecurity, including school-based nutrition programs18  and food banks.19  
Refer families to community-organized, culturally and linguistically relevant, updated SDH resource links (eg, Hispanic Alliance, Greenville, SC20 ; Informed Immigrant Resources21 ; Immigrants Rising22 ; Aunt Bertha23 ). 
 Immigration enforcement and policy Acknowledge fear and uncertainty that families are facing and offer resources, including Know Your Rights materials.24  
Familiarize yourself with legal resources for immigrant families25  who face particular risks for lack of access to public services or immigration enforcement. 
For hospitals and health care systems  
 Health care access and delivery Ensure that free testing for COVID-19 is accessible and advertised to immigrant families.  
Develop and implement free walk-up and drive-through testing and treatment (eg, New York City, NY26 ; Trenton, NJ27 ) sites within trusted venues in immigrant communities, such as schools, community centers, or places of worship. 
Increase capacity for access to interpreters and patient navigators to facilitate telehealth. 
Rapidly employ and train bicultural, bilingual professionals and paraprofessionals (eg, community health workers28 ) to assist with COVID-19 testing and information dissemination in densely populated immigrant communities. 
 Socioeconomic impacts Implement and/or expand systems-wide screening for social determinants of health in the setting of COVID-19.29  
Ensure continued access to social workers, community health workers, and other team members dedicated to connecting families to resources such as unemployment, nutrition, housing, and other public and community-based programs. 
 Immigration enforcement and policy Post welcoming signage30  that offers families a sense of safety while seeking health care services.  
Ensure that any security presence during visitor and patient screening protocols is trained to offer culturally relevant, sensitive screening that recognizes disparate impact of law enforcement on communities of color, including immigrant families.  
Develop protocols that ensure the rights of immigrant families are maintained31  while seeking health care. 
For policymakers and public health entities  
 Health care access and delivery Develop and disseminate smartphone-accessible resources32  and materials in multiple languages.  
Clarify access to free testing and treatment regardless of immigration status (eg, New York City33 ).  
Encourage states to provide Medicaid to all individuals regardless of immigration status, including those with DACA, TPS holders, green card holders, and undocumented individuals, to ensure that they have access to testing and treatment.  
Ensure access to data stratified by race, ethnicity,34  and language preference to better implement interventions that meet the needs of communities who are most impacted. 
Suspend public charge enforcement. 
 Socioeconomic impacts Ensure that resources on public websites about COVID-19 include accessible, multilingual information regarding access to housing, food, and other critical services (eg, Chicago, IL35 ; Boston, MA36 ).  
Include all immigrants, regardless of legal status, in any federal or state financial relief package (Chicago, IL37 ). 
Expand unemployment eligibility to people with DACA and TPS and to others who have work eligibility. 
Automatically extend work permits for individuals with DACA, TPS, and nonimmigrant visas for the same time period as the individual’s status or work authorization. 
Place a moratorium on housing evictions and foreclosures,38  utilities termination,39  and suspended telephone or Internet services.40  
 Immigration enforcement and policy Develop timely and well-communicated protocols for immigrants in ICE custody who fall ill, and immediately close the 3 family detention facilities, ensuring monitoring for symptoms with community-based case management.  
Resume access to humanitarian protection at the US–Mexico border for unaccompanied children and family units.  
Stop interior ICE enforcement unless someone has a criminal background that threatens public safety. 
Continue DACA renewals, including work authorization, and resume acceptance of new applications. 

Recommendations within each category are listed in order of increasing expected time commitment or complexity. SNAP, Supplemental Nutrition Assistance Program.

Amid unprecedented challenges presented by COVID-19, baseline inequities in health care access and delivery for CIF are exacerbated. Nearly half of undocumented immigrant adults and 25% of lawfully present immigrant adults are uninsured. Similarly, 1 in 3 undocumented children and nearly 1 in 5 lawfully present CIF are uninsured. US-born CIF with ≥1 noncitizen parent are more often uninsured than children with citizen parents (8% vs 4%).41  The Families First Coronavirus Response Act, passed on March 18, 2020, provides COVID-19 testing for uninsured individuals through Medicaid. However, millions of CIF remain ineligible for Medicaid, including some children with lawful permanent residency status,42  people with Deferred Action for Childhood Arrivals (DACA), and those granted temporary protected status (TPS) because of conditions considered unsafe for return to the home country. Although the subsequent Coronavirus Aid, Relief, and Economic Security Act expands free COVID-19 testing at federally qualified health centers, the bill excludes treatment costs.43  Furthermore, parental LEP is a risk factor for poor outcomes among children, including less diagnostic testing and higher rates of complications and adverse events.3  Professional interpreters are underused, and LEP families report poor access to health information and education resources. The current milieu of limited in-person interpreter capacity due to social distancing, insufficient multilingual resources, and lack of interpretation standards for telehealth may impede health care delivery for LEP families.

A climate of fear and uncertainty for immigrant families underlies the health impacts of this pandemic. In February 2020, the federal government implemented sweeping changes to public charge regulations, which permit denial of visas or green cards to immigrants deemed likely to become economically dependent on the government. The changes expand the programs considered in public charge determinations, including Medicaid for adult immigrants. Although the new public charge regulation excludes Medicaid for eligible CIF, millions of eligible CIF are projected to disenroll from and/or not initiate enrollment in Medicaid and other safety net programs.44  This “chilling effect,”44  heightened by ongoing immigration enforcement, may prevent immigrant families from seeking medical and mental health care for COVID-19. CIF at high risk for complications, including children with immunocompromising conditions or underlying pulmonary pathology, face particular vulnerability to severe outcomes with delayed care.45  In forgoing timely evaluation or treatment, immigrant families may also unknowingly risk virus transmission within multigenerational homes and close-knit communities.

With awareness of inequitable health care access and health outcomes for CIF, pediatricians are uniquely positioned to elevate concerns and support the care of CIF during COVID-19. Key recommendations include proactive outreach to immigrant communities to disseminate culturally relevant public health resources and timely information regarding immigration policy and COVID-19, development of equitable telehealth workflows, and advocacy for access to professional interpreter services.

Immigration status is a social determinant of health (SDH). CIF are more likely to experience poverty, food insecurity, housing instability, and lower educational achievement compared with national averages. Immigrants disproportionately work in low-wage jobs without paid leave, and shelter-in-place mandates may result in unemployment for parents without child care. Additionally, the chilling effect of public charge has impacted enrollment in the Supplemental Nutrition Assistance Program and the Women, Infants, and Children Program (WIC), although WIC is exempted from the public charge rule. Housing vouchers are also included in public charge determinations, discouraging even qualifying families from participation. With the economic consequences of COVID-19, food and housing insecurity may rise among all demographic groups, and CIF face particularly high risks because of inequitable policies. When addressing SDH, pediatricians may be caught between encouraging families to participate in programs that keep them healthy and navigating confusing regulations around eligibility based on immigration status. Pediatricians can remain informed and educate others regarding evolving eligibility for benefits,46  compile resources to address SDH (Table 1), and offer timely referrals.

Other protective public health decisions with anticipated negative repercussions may disproportionately affect CIF who experience poverty. Schools across the country have closed to reduce COVID-19 transmission, affecting >50 million children.47  Emotional disturbances from unstructured schedules and decreased peer interaction, lack of supervision when parents must continue to work, and academic regression could detrimentally impact the long-term development of CIF. With many schools now offering classes online, the achievement gap may widen further because immigrant Latinx families in particular are less connected to broadband Internet than other low- and moderate-income families.48 

The aforementioned Coronavirus Aid, Relief, and Economic Security Act is a $2 trillion federal stimulus effort to mitigate economic consequences of the pandemic. However, if anyone in a household uses an Individual Taxpayer Identification Number (common among immigrant families), the entire household is excluded from the direct cash assistance that is a centerpiece of the stimulus, even if some family members have Social Security Numbers. This is particularly harmful to the >7 million US-born children in mixed-status families who will not qualify for this cash assistance. Denying relief to millions of mixed-status families places an inequitable burden on CIF.

Despite COVID-19, Immigration and Customs Enforcement (ICE) activity continues. As of March 18, 2020, ICE “temporarily adjusted” enforcement to focus on “public safety risks and individuals subject to mandatory detention based on criminal grounds” but still gives leeway to “exercise discretion.” This creates unnecessary fear of family separation for CIF who are already facing socioeconomic and psychosocial difficulties during this pandemic. Additionally, people with DACA, including ∼27 000 working in health care, remain in limbo as they await the Supreme Court decision.49  Nearly all with DACA are bilingual, an invaluable asset as telehealth becomes integral to health care delivery. Immediate continuation of the DACA program, including renewals and acceptance of new applications, could mobilize a multicultural workforce to mitigate worsening and emerging inequities.

With the threat of COVID-19, risks for families seeking safe haven in the United States are magnified. People subject to the Migrant Protection Protocol (ie, “Remain in Mexico”) experience crowded, violent conditions on the Mexican side of the United States-Mexico border. Conditions in Customs and Border Protection processing centers and ICE family detention centers are unsanitary and lack health care services at baseline.50  Unaccompanied immigrant children remain in group shelters, and immigrant adults are imprisoned in densely populated detention facilities. These conditions predispose migrant families to rapid COVID-19 transmission and increase risks for serious illness given known gaps in health care provision.

COVID-19 does not discriminate on the basis of immigration status, and neither should the measures to lessen the impact. Pediatricians can help to mitigate exponential growth of health inequities for CIF during this pandemic. Strategies within and beyond health care systems must incorporate policy and public health approaches that are compassionate, culturally relevant, and equitable.

We thank Tamar Magarik Haro, Senior Director, Federal and State Advocacy at the American Academy of Pediatrics for critical review of this manuscript.

Drs Cholera and Linton conceptualized the Perspectives piece; and all authors drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr. Cholera is supported by the Duke National Clinicians Scholars Program which is housed in the Duke Clinical and Translational Science Institute (UL1TR002553).

     
  • CIF

    children in immigrant families

  •  
  • COVID-19

    coronavirus disease

  •  
  • DACA

    Deferred Action for Childhood Arrivals

  •  
  • ICE

    Immigration and Customs Enforcement

  •  
  • LEP

    limited English proficiency

  •  
  • SDH

    social determinant of health

  •  
  • TPS

    temporary protected status

  •  
  • WIC

    Women, Infants, and Children Program

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.