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Children Should Be Cared for, Not Caged

Alan Shapiro, MD, FAAP
January 6, 2017

Editor's note: An American Academy of Pediatrics (AAP) delegation recently toured the U.S. Customs and Border Protection Processing Center in McAllen, Texas. The group included AAP's Immediate Past President Benard Dreyer, MD, FAAP, President Fernando Stein, MD, FAAP, and Immigration Health Special Interest Group members Alan Shapiro, MD, FAAP, Julie Linton, MD, FAAP, Joyce Mauk, MD, FAAP, Kimberly Avila Edwards, MD, FAAP, Marsha Griffin, MD, FAAP, Padma Swamy, MD, FAAP, and Judy Dolins, MPH. With contributions from Drs. Swamy, Avila-Edwards and Mauk, Dr. Shapiro shares this report.


I'd seen pictures of the facilities where children and families are detained after they cross the U.S. border and are apprehended.  As a pediatrician who advocates for the unique medical and mental health needs of newly arrived immigrant children, I've even used such pictures in presentations.  But seeing caged children first-hand on a recent visit to a Customs and Border Protection processing center was a very different experience, one that left me with a profound sense of sadness and injustice.

The November trip was the latest of several made by American Academy of Pediatrics (AAP) leaders and members of its Immigrant Health Special Interest Group to better understand reports of harsh conditions where the children are held.  We arrived the day after the presidential election,  which had been punctuated by a blistering debate over immigration.  The irony of timing was not lost on any of us. ​

"Upon entering the holding area, we encountered the ghostly images of children wrapped in silvery Mylar blankets – the kind draped over marathon runners at the end of a race."

A Vulnerable Population
Record numbers of unaccompanied immigrant children and families began crossing our southern border in 2014.  More than 68,500 unaccompanied children made the journey that fiscal year alone, and while the numbers dipped in 2015, they rose sharply last year. In fact, the numbers of "family units" (mostly women and children) reached a record high of 77,674 in 2016.  Ongoing violence in the Northern Triangle countries of Honduras, El Salvador and Guatemala, superimposed on abject poverty and lack of government protection, has fueled this exodus.

Seeking safe haven, migrants come in contact with the labyrinthine American immigration system, which can be a source of solace but also pain. The first stop for someone who is apprehended is one of the U.S. Customs and Border Protection's processing centers. Reports about these centers have cited cold temperatures, little food, open toilets, lack of showers and scant medical care. The detainees call them las hieleras (iceboxes) or las perreras (dog kennels). ​

La Perrera Grande
Our delegation arrived at the largest processing center on the border, known as Ursula Central Processing Center in McAllen, Texas. The building, hidden behind a fence, was a drab and nondescript warehouse; the only identifier being a white placard stating that this was property of the U.S. government. One could have imagined it contained almost anything other than women and children.

Our tour guide demonstrated empathy toward the detainees and at times was apologetic that the setting was not more child friendly. The only color we saw was the orange of recycled T-shirts given to the detainees.

Upon entering the holding area, we encountered the ghostly images of children wrapped in silvery Mylar blankets – the kind draped over marathon runners at the end of a race. Indeed, they too had endured their own marathon, having just finished a 2,000-mile or longer journey to escape unspeakable violence.

We were astounded by the enormity of the 55,000-square-foot space, the bright lights, the smell of porta-potties, and the mass of chain link fences topped with netting. These fences created four giant cages holding boys, girls and mothers with young children. There was one small area that held adult men. The children ranged from infants to older adolescents. The near silence of the center was unsettling; the only sound was the crinkling of the blankets. Understandably, the detainees were dead tired and frightened. The windowless environment was more disorienting because the lights were kept on 24/7, for "safety reasons."

The visit was especially poignant for Kimberly Avila Edwards, MD, FAAP, a member of our delegation, after she locked eyes with a child who resembled her son.

"Undoubtedly, he only looked through me, as I was another adult in a sea of strangers," she recalled. "It was in that brief glance, that I appreciated the same deep, dark brown eyes, the same color of hair, and same age as my own son.  I felt visceral angst bringing me to tears, as I could only imagine the utter fear that my son would experience if he were in this situation, separated from me.​

"We will continue to advocate for better conditions for children and families seeking safe haven, regardless of national borders or politics."

​Processing Unaccompanied Children and Family Units
This little boy was one of more than 700 faces of immigrants who had been picked up and brought to the center the prior night, and this was a slow night. This center has the capacity to hold 1,000 migrants. They are detained up to 72 hours before being transferred. Unaccompanied children will be sent to children's shelters throughout the country contracted by Office of Refugee Resettlement, while families either are sent to family detention centers or, if lucky, released to the community.

In Ursula, there are private toilets, showers and clean, dry change of clothes if detainees arrive before 7 p.m.; those unlucky to arrive late sit in wet clothes until the morning.  Old clothes, shoes and other belongings, like backpacks and stuffed animals, are sealed away in individual plastic bags. The mound of these bags drove home the fear and isolation these children must feel.  Our guide told us three meals were provided each day.

Medical care provided is cursory at best and takes place in the open behind curtained screens. Detainees are checked for scabies, lice and obvious signs of infectious disease, such as active chicken pox lesions. Vital signs are not taken.

Those who need more detailed exams are taken to a small, cold "medical room." There was a small cabinet with over-the-counter meds, and pictures of infectious diseases adorn the walls. We were told that emergency responders were called for those who appeared ill or injured upon apprehension in the field.

We Need an Alternative to Detention
We were told the job of Customs and Border Protection is to protect our borders, not care for detained children. Its role has evolved, however, as the surge of children and families has overwhelmed resources and created a backlog of detainees. Compounding this situation is the little training border patrol receives on trauma-informed care and vicarious trauma. Based on what we heard from our guide, caring for these children takes its toll. Our delegation felt true respect for the work that border patrol agents have unexpectedly had to assume. 

As a nation, we need to decide who, in fact, should be caring for children apprehended at the border seeking safe haven. We should come up with a more humane way to process this vulnerable population without further re-traumatization. Ursula processing center was stunningly bright and clean, a "showcase" center. We were denied access to the reportedly grittier processing stations where the majority of children first get taken before being transferred here. We couldn't help but wonder what we would have seen there.

We will continue to advocate for better conditions for children and families seeking safe haven, regardless of national borders or politics. Children should be placed in the hands of child-welfare professionals and be given access to state-of-the-art medical and mental health care. Their first experience in this country should be one that maintains their dignity and demonstrates our own humanity.

As pediatricians, we are taught to care for all kids equally regardless of race, gender and socio-economic status. Let us not forget, legal status as well.  ​​​

The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics. ​​​


​​​Ab​out the ​​Author

Alan Shapi​ro, MD, FAAP, is Senior Medical Director of Community Pediatric Programs at Children's Hospital at Montefiore and Co-Founder and Medical Director for Terra Firma: Healthcare and Justice for Immigrant Children. 

​​Contributing Authors

Padma Swamy, MD, FAAP, Academic General Pediatric Fellow at Texas Children's Hospital in Houston.

Kimberly Avila-Edwards, MD, FAAP, Chapter Chair of the Texas Pediatric Society, Texas Chapter of the American Academy of Pediatrics and a general pediatrician in Austin.

Joyce Mauk MD, FAAP, President of the Texas Pediatric Society, Texas Chapter of the American Academy of Pediatrics,  Sheila Morris Uhr Chair in Developmental Pediatrics and Distinguished Consultant at Cook Children's Physician Network and CEO/Medical Director Child Study Center in Fort Worth, TX.​