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Dando Poder a Nuestras Familias: A Story of Childhood Immigration and Access to Care

Molly Markowitz, MD and Rebecca Webb
June 22, 2018

Sofia* spent the first years of her life in Central America, known for its ancient Mayan ruins and cloud shrouded rainforests. It’s also known for its increasingly powerful drug cartels and gangs, and one of the world’s highest violent crime rates.

When gang members threatened to kill the Sofia and her mother unless they paid “taxes” to ensure their safety, the two of them fled in hopes of seeking asylum and joining family living in the United States. If they stayed, they knew that local police could do little to protect them.

Thousands of refugees begin their journey from Central America by climbing onto the roof of La Bestia (The Beast), a cargo train running north through neighboring Mexico. For weeks, they cling to the roof of a pitching and weaving train, constantly fighting hunger, thirst, and exposure to the elements.

As vulnerable immigrants traveling by train, on foot, and with the help of a “coyote” (human smuggler) through foreign lands, Sofia and her mother were witness to and victims of horrific physical and sexual violence which is far too common along the way.

After weeks of traveling, they finally crossed the US-Mexican border and were quickly apprehended by the Border Patrol. Uncertain of their future, they spent their first several nights in a Customs and Border Protection processing center. They and other undocumented immigrants were housed in cells commonly referred to as hieleras (iceboxes) because of their freezing temperatures, where the girl developed a cough.

Sofia and her mother successfully passed a credible fear interview, qualifying them to apply for asylum. But their fate was still in limbo, with a follow-up court date scheduled months later. They were trapped in a perpetual state of anxiety about their future, while trying to understand the horrific trauma and loss from their past.

The cough Sofia developed in the detention center progressed into a severe pneumonia. Mother and daughter eventually sought medical treatment, and the girl ended up hospitalized. This first contact with the healthcare community provided mother and daughter the opportunity to finally expose and share the wounds of their traumatic experiences from the past.

Already traumatized by violence they encountered back home and on their harrowing journey to the United States, immigrants experience additional traumas once they arrive and seek asylum, @AAPSOPT’s Dr. @mollymarkowitz & Rebecca Webb write in #AAPvoices.

Despite finally receiving medical treatment, however, the events over the past year would likely haunt them for years to come. Substantial scientific evidence demonstrates how “toxic stress,” the accumulation of repetitive and sustained emotional and physical trauma that ultimately leads to a physiological stress response in the body, negatively impacts long-term health and wellbeing. Children who experience toxic stress are at an increased risk of heart disease, lung disorders, depression, illicit drug use, alcohol abuse, and suicide. 


Already traumatized by the violence they encountered back home and on their harrowing journey to the United States, immigrants experience additional traumas once they arrive and seek asylum. The Kaiser Family Foundation  recently held focus groups with documented and undocumented immigrant families. They shared examples of ongoing toxic stressors such as fear, uncertainty, racism, discrimination, bullying, anxiety, depression, and psychosomatic symptoms. As the interviews also revealed, these stressors led to decreased use of vital healthcare services. The findings suggest our current immigration system and political climate are contributing to toxic stress and are inhibiting access to care.

Sofia is just one example of a child cared for in our local health systems, but pediatric providers across the country are treating the youngest of refugees who have been through similar traumas. As pediatric providers and trainees, we need to be ready to help them. We’ve learned there are several ways we can make a difference in their health and well-being.

"As vulnerable immigrants traveling by train, on foot, and with the help of a 'coyote' (human smuggler) through foreign lands, Sofia and her mother were witness to and victims of the horrific physical and sexual violence that's far too common along the way."


First, we know that the harmful health effects of toxic stress can be buffered by promoting resilience. We can foster this intangible strength by facilitating social connections with our patients, providing concrete help when needed, educating families about positive parenting strategies, and supporting the social and emotional needs of families.

We can also educate ourselves and our peers about the unique toxic stressors experienced by immigrant children and families. The American Academy of Pediatrics’ Immigrant-Child-Health-Toolkit is a good place to start.  This allows us to understand the entire health story of these patients, and how their experiences from the past, present, and future will impact their health and wellbeing for years to come.

As advocated by the AAP’s Section on Pediatric Trainees (SOPT) Access4Kids campaign, we can help ensure access to all-encompassing healthcare, including but not limited to medical, mental health, legal, and social services. Through these vital connections, immigrant families can be empowered with information about their immigration status and form strong connections, allowing for their children to heal and hopefully thrive in their new home.

Equally important, we can work to foster a safe and welcoming healthcare environment to promote access to vital healthcare services. This can be done by first acknowledging the hardship and insecurity experienced by immigrant families and then by reassuring them that you, as a medical provider, will not share their immigration status with authorities or document their immigration status in healthcare records. By creating this safe, secure space, we can support families in seeking the healthcare they need.

* Due to the sensitive  nature of this issue, the patient's identity has been changed to ensure privacy. 
* The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics.

About the Author

Molly Markowitz, MD, a general pediatrics resident at Yale New Haven Children’s Hospital, is Executive Coordinator of Medical Student Initiatives for the American Academy of Pediatrics Section on Pediatric Trainees.



Rebecca Webb is a medical student at Boston University School of Medicine and Assistant Representative for District One, American Academy of Pediatrics Section on Pediatric Trainees.






The authors express their sincere gratitude to Carmen Rosa Noroña LCSW, MS.Ed.,CEIS, Child Trauma Clinical Services, The Child Witness to Violence Project, Boston Medical Center and Jason Zhang, MD, a pediatric resident at Boston Combined Residency Program, for sharing their experiences and expertise on caring for immigrant children.

This image is from the AAP Section on Pediatric Trainees Advocacy Campaign and was created by high school students from Burlington, VT in order to foster togetherness in their community. Trainees are encouraged to post this image and share in their communities.