Care and the caravan: the unmet needs of migrants heading for the USBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5315 (Published 19 December 2018) Cite this as: BMJ 2018;363:k5315
Thousands of Central American migrants travel north through Mexico to the southern US border every year. In the run-up to recent midterm elections, US president Donald Trump referred to these refugees as an “invasion.” The “caravan” has received widespread media attention, sparked backlash, and inspired more asylum seekers to band together for safety.
But the exodus from this part of the world is far from new. Consistently, in recent years, more than 500 000 migrants are estimated to enter Mexico clandestinely at its southern border each year.1 Most are leaving the “northern triangle” countries of El Salvador, Guatemala, and Honduras, with their sights set on the US.
Throughout the tough and dangerous journey, access to healthcare is limited.2 Shelters, physicians, and rights advocates are responding to this humanitarian crisis, offering very limited health services along the route while urging regional governments to collaborate on policies to protect this vulnerable population.3
Crime, corruption, and climate change
Endemic violence and corruption and lack of economic opportunity in their home countries are among the “perfect storm of factors fuelling migration,” said Daniella Burgi-Palomino, senior associate at the Latin America Working Group, an advocacy organisation based in Washington, DC.
Violence committed by gangs, security forces, vigilantes, and in the home is widespread. The northern triangle countries have among the highest homicide rates in the world outside of war zones and some of the highest rates of sexual and gender based violence.456
Hundreds of thousands of people are forcibly displaced from their homes and often cannot access health services while in hiding.7 In addition, the region’s extreme wealth inequality is compounded by food insecurity linked to climate change, exacerbating hunger, malnutrition, obesity, and child stunting.8
Despite some conservative US pundits suggesting that migrants may bring smallpox, leprosy, or tuberculosis to the US,910 most are in reasonable health—smallpox was eradicated globally in 1980, and Mexican authorities have not documented any cases of leprosy or tuberculosis.11
Xóchitl Castañeda, who has been director of the Health Initiative of the Americas at the University of California at Berkeley for two decades, said that migrants are “very resilient people” who generally leave in a healthy state, with up to date vaccinations and the strength to endure the long journey and “perform the most dangerous, diminishing, difficult jobs” once they arrive.
Some migrants no longer aim to reach the US or Mexico. Immigration crackdowns in those countries have made neighbouring Central American countries such as Belize, Costa Rica, and Panama increasingly attractive for asylum seekers.12 Most, though, continue along the dangerous route north.
Shelters and volunteer physicians
María Hernández coordinates the migrant programme launched in Mexico by Médecins Sans Frontières (MSF) in 2012. She told The BMJ that the “hardest part” of the journey is crossing Mexico’s southern and northern borders.
Because migrants often travel clandestinely to avoid the authorities, they are particularly vulnerable to attacks by criminal groups, to armed robbery, kidnapping, and sexual violence. They are also exposed to harsh weather without adequate food, water, shelter, or medicines. The most common resulting health problems are dehydration; respiratory, gastrointestinal, and skin infections; sore muscles; blistered feet; and injuries from attacks or accidents.13
Rámon Márquez, who runs the shelter La 72 in the small southern Mexican town of Tenosique, told The BMJ that when it opened almost eight years ago migrants “would stay two or three days” before jumping aboard the cross country freight train nicknamed “The Beast.” Limbs and even lives have been lost falling from the train.14
In 2014, everything changed. The Southern Border Plan, a US backed Mexican immigration policy, deployed officials to stop migrants from riding the train or walking along the tracks, diverting them to more obscure and insecure routes.
That’s when, Márquez said, La 72 became a “refugee camp,” with migrants staying for months rather than days.
In response, in 2015 Márquez began partnering MSF, which currently has two psychologists and two physicians on site. The shelter has received more than 90 000 migrants since it opened in 2010, several thousand of whom have had consultations and care from MSF.
A lot of violence
“We see in our consultations that independent of the reasons for which a person leaves their country, what they find along the route is a lot of violence,” Hernández said. Almost 90% of migrants treated by MSF in Mexico report having experienced violence, with 75% saying it has caused them lasting harm, Hernández says.
Many Central American migrants do not know their rights or what health services are available to them in Mexico. And many are afraid to access care because of stigma, discrimination, lack of funds, security concerns, or fear of deportation.3
In 2014, the Mexican government authorised migrants, regardless of their legal status, to have free health services for 90 days. The policy was meant to remove barriers to accessing care, but many migrants are unaware that it exists, have faced discrimination at hospitals, or have been forced to pay.15
The Mexican president Andrés Manuel López Obrador, sworn in on 1 December, has promised a humane approach to migrants, including through expanded work visa programmes. But the tension at the US border and the growing refugee population are already testing his administration’s capacity.16
Many hospital staff in Mexico have not been trained to treat migrants or don’t follow protocols—for identifying survivors of sexual violence, for example, which is so common that many women and girls use contraceptives before migrating in anticipation of being raped.7
Without privately run shelters, volunteer doctors, and advocates accompanying migrants, Márquez, Hernández, and Burgi-Palomino told The BMJ, it would be difficult if not impossible for them to access care on the journey.
Backlogs, detention, and deportation
The administration of US president Donald Trump has ramped up immigration enforcement, used the migrant “caravan” to stoke anti-immigrant sentiments, deployed thousands of soldiers to the US-Mexico border, and attempted to block applications for asylum from migrants who do not enter at an official port of entry.171819
At many crossings along the US southern border, backlogs mean the wait to apply for asylum can be several years—and most claims are being denied.20 Hence more migrants are stuck for longer in Mexican border cities like Tijuana, where thousands of new caravan members are joining the thousands already waiting.
A coordinated response is needed at Mexico’s northern border, said Burgi-Palomino. “The concentrated presence of a large number of people requires a coordinated humanitarian response from experts, keeping health and hygiene concerns in mind.”
But basic supplies and medical services in Tijuana’s camps are severely lacking, according to US immigration lawyers and activists based in Los Angeles who visited the sites recently. They are planning to bring donated supplies and volunteer physicians.
Detention centres in the US
In the US, more than 300 000 migrants are apprehended each year, and they are likely to be held in immigration detention centres, which house about 30 000 immigrants nationwide on any given day.21 The average stay is just over one month, but some immigrants are detained for years.22
There are no legally enforceable standards for the conditions. The Office of Inspector General and rights groups have expressed concerns about treatment and care in US immigration detention centres for years. Medical neglect tops the list of abuse complaints by detainees received by the non-profit group Freedom for Immigrants. Abuses disproportionately occur in privately run detention centres, which hold about three quarters of the detainees.
For those who stay in the US long term, whether documented or undocumented, lack of access to healthcare continues, said Castañeda, who has worked at the intersection of migration and health in the Americas for more than 20 years. Immigrants are less likely to have health insurance or to be able to afford preventive care, and often they face language or cultural barriers to access. Hispanics have the highest uninsured rate of any group in the US, according to the US Health and Human Services Department.
Although immigrants typically arrive in good health, Castañeda said, after five to 10 years in the US their “health capital” tends to deteriorate, often from a lack of access to healthcare, occupational hazards, or diabetes and obesity linked to poor diet.
Providing healthcare in the shadows
The biggest challenges to providing healthcare to Central American migrants are linked to their invisibility. Migrants are mobile, and criminalisation of their movements pushes them further into the shadows.
“We have to make sure status is not a barrier to appropriate healthcare,” said Burgi-Palomino.
To ensure safe transit for migrants, Burgi-Palomino suggests that governments in the region should collaborate with civil society groups, international humanitarian organisations, and the volunteers already operating on the ground.
Hernández adds that “governments should approach the problem from a more human point of view, guaranteeing safe transit, and access to health services and protection for the most vulnerable, such as women, children, and the LGBTI (lesbian, gay, bisexual, transgender, and intersex) community.”
Some regional cooperation has already begun, at least on paper. Last year, the health ministers of 10 Mesoamerican countries signed a declaration with the Pan American Health Organisation, agreeing “to work together to meet the health needs of migrants.”23
“Migration is a global phenomenon and what we are experiencing is not very different from what Europe is experiencing,” Castañeda said. “We need to prepare the physician workforce to understand the specific needs of this population, and not just the technicalities but also in terms of humanisation and solidarity.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.