The impact of COVID-19 on the mental health of migrants and asylum seekers
Sergio Aguilar-Gaxiola, MD, PhD,i María Elena Medina-Mora, PhD,ii
Clarisa Reyes-Becerra, JD,iii and Gustavo Loera, EdDi
i UC Davis Center for Reducing Health Disparities, Sacramento, California
ii Instituto Nacional de Psiquiatría Ramón de la Fuente & Universidad Nacional Autónoma de México, Ciudad de México
iii California Rural Legal Assistance Foundation, Sacramento, California
The trauma of migration prior to COVID-19
Migration or a mixed movement involving people migrating to seek better economic opportunities that improve their quality of life and that of their families left behind is prompted by the migrants’ need to escape armed conflicts, violence, and persecution threatening their lives, and to reunify with parents and family members living abroad.
A recent study found that many asylum seekers from Central America became victims of criminal organizations where many were robbed, kidnapped, abused, raped, tortured, and killed during their migration journey1. Once at the border, migrants are faced with a new wave of traumatic experiences. It’s been reported that, at detention centers, they encounter overcrowded, unsanitary and inhumane conditions.
Living in unhygienic conditions unnecessarily increase the migrants’ risk of contracting COVID-19. In some instances, migrants have claimed experiencing excessive use of force, sexual assault, and improper solitary confinement as forms of punishment. The prolonged stay in these detention centers leads to more trauma, physical and psychological distress, and mental illness2.
Another painful experience impacting migrants were family separations, one of many federal policies by the Trump administration’s efforts to curtail immigration, that resulted in the separation of an estimated 3,900 to 4,100 migrant children from their parents3.
The long-term impact on children’s mental health and wellbeing is severe. According to Dr. Jack Shonkoff, who directs Harvard University's Center on the Developing Child, "decades of peer-reviewed research shows that detaining kids away from parents or primary caregivers is bad for their health.” He added, "Early experiences are literally built into our brains and bodies…Stable and responsive relationships promote healthy brain architecture…If these relationships are disrupted, young children are hit by the double whammy of a brain that is deprived of the positive stimulation it needs, and assaulted by a stress response that disrupts its developing circuitry"4. Of course, the parents’ mental health is negatively impacted as well. In the U.S., migrants continue to be exposed to multiple adverse experiences and poor health and mental health outcomes such as racial discrimination and hate crimes. This exposure to a climate of racism and fear creates more stress, anxiety, uncertainty, and mistrust among migrant communities.
The mental health status of migrants during COVID-19
The COVID-19 crisis and recent fires in the U.S. West coast has added new layers of stressors and anxiety to the social, economic, environmental, and emotional burdens already present in the lives of underserved and migrant communities.
The pandemic has amplified disparities in mental health impacting migrants and increasing their risk of contracting COVID-195. For migrants trapped in shelter camps at the U.S. southern border and denied entry or an opportunity to request sanctuary are more vulnerable to COVID-19 and furthering these anxieties, stressors, and traumatic experiences, and mental health issues. Moreover, without adequate access to preventive care, migrants are at greater risk of health conditions such as obesity, hypertension, asthma6, and diabetes7, that when combined with anxiety, depression, and PTSD can led to more severe cases of COVID-19 and sometimes death.
With recent data from U.S. Center for Disease Control and Prevention (CDC) showing Latinos both adults and children having a greater likelihood than Whites in contracting COVID-19, past research on health disparities, demonstrates a treatment gap and other indicators of inequities and vulnerabilities that can explain the increased risk and higher rates of COVID-19 infections, hospitalizations, and deaths among Latino migrants8.
Poverty, a social determinant linked to mental disorders, is more prevalent among migrant communities and has made migrants more vulnerable to COVID-19 and mental health issues. Migrants are more likely to keep working despite the high risks of illness and infection because they are not able to access unemployment benefits or economic relief.
We are also witnessing a digital divide in migrant households during the COVID-19 pandemic that also contributes to mental health inequities. Access to technology and internet is strongly associated with health literacy. This connection has become more pronounced during the pandemic, in particular for mental health providers attempting to engage migrant farm workers in rural locations using telehealth technology.
Health care, essential workers, and human rights for migrants during COVID-19
During COVID-19, migrant populations faced increased barriers to accessing health care and many continued to work as “essential workers” despite hazardous work conditions and few guarantees of employers ensuring safety and health precautions during the pandemic.
In March of 2020, the U.S. Congress passed both the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act, both of which meant to expand access to testing and treatment for COVID-19 by requiring insurance companies to cover items and services related to COVID-19 diagnostic testing9.
Unfortunately, this coverage was limited to testing and not treatment, and it was up to individual states to expand coverage for COVID-19 treatment, particularly for the uninsured. This presented a problem for migrants in the United States, especially those who are undocumented and uninsured. Moreover, the U.S. Department of Health and Human Services recently rescinded much of the Affordable Care Act’s previous language access guidance, making it more difficult for patients with limited English proficiency to have meaningful access to health care10.
At the same time, the “public charge test,” a rule by immigration agencies instituting more stringent wealth and income requirements to qualify for an immigrant visa or legal permanent residency, has caused a “chilling effect” among migrant communities. As a result, eligible migrants have avoided enrolling in or disenrolled from public benefit programs, including public health insurance and public health services, for fear of immigration consequences11.
Migrants have also been largely left out of federal disaster relief efforts. While the CARES Act created provided Economic Impact Payments to individuals and families as a form of financial assistance during the COVID-19 pandemic, the majority of undocumented immigrants, even those who file taxes, and individuals (citizen and immigrant) living in mixed-status families did not qualify to receive this relief12. Although the FFCRA created emergency paid sick and family leave provisions during the COVID-19 pandemic13, many migrants were deemed not eligible despite these protections were supposed to be available to everyone, regardless of immigration status. Again, many migrants fear retaliation or losing their job if they ask for time off.
This is an unfortunate reality for the more than six million estimated migrants who work in “essential” and front-line industries such as health care, grocery and pharmacy retail, manufacturing, cleaning and janitorial services, and agriculture14. Finally, even though federal and state agencies have released guidance in protecting the health and safety or workers during the pandemic, migrant workers have had to continue to work despite hazardous conditions.
For example, in California, which has instituted stringent protections for workers during the pandemic, a Foster Farms chicken processing plant was ordered to shut down by Merced County Health Department after eight confirmed deaths and more than 300 positive cases15.
The resilience of migrants to overcome adversity
According to UNICEF (2017)16, resiliency is the capacity to overcome adversities, transform and rebuilt oneself and thus goes beyond just facing and adapting to difficulties. This capacity is related to the understanding and resignification of experiences, flexibility to adapt and rebuilt, of building trust that difficulties can be curbed.
The migration process is related to multiple adverse events, that includes harsh living conditions, uncertainty, fear, insecurity, loss of social status and difficulties with the language, discrimination, exclusion, bullying, rape, torture with little protection or external support17. Systematic reviews have linked forced migration to its context with an increased risk of psychopathology like that observed in areas in conflict or war, mainly PTSD, depression, anxiety, suicidal thoughts and behaviors and childhood internalizing and externalizing disorders. Resiliency has been found as an inverse predictor of psychological distress18.
According to Gómez-Gutiérrez19, resiliency is part of a human essence that leads to survival. Migrants from Central America make the arduous journey to the U.S. to escape the harsh conditions (e.g., structural violence, poverty, domestic violence), from their country with the prospect of securing a better future for their children20.
Religious beliefs and supports have also been interpreted as a source of strength associated with resilience. Researchers examining the strengths and resilience of a group of migrant women in Tijuana, Mexico found that internal strengths (i.e., religious beliefs, courage, endurance, and goal setting), and external (i.e., support received from people, institutions and their families) played a key role in their survival21.
Therefore, resilience means adapting to a new environment, achieving social cohesion and belonging, integrating and shaping new identities, and gaining satisfaction out of life and persisting to achieve goals.
Proven interventions that focus on adverse events, personal and environment resources, and coping mechanisms can lead to resiliency that can curve the pathways to trauma and mental illness. Collaborative strategies are necessary to strengthen the governmental and civil society response to mental health needs. Actions are also needed to further the understanding of the mental health impact of forced migration22. Such solidarity from all community stakeholders will lead to productivity and economic prosperity with benefits for migrants, their families, their communities and society as a whole.
- Garcini, L. M., Peña, J. M., Gutierrez, A. P., Fagundes, C. P., Lemus, H., Lindsay, S., & Klonoff, E.A. (2017). One scar too many”: The associations between traumatic events and psychological distress among undocumented Mexican immigrants. Journal of Traumatic Stress, 30, 453–462. http://dx.doi.org/10.1002/jts.22216.
- Mercado, A., Venta, A., Henderson, C., & Pimentel, N. (2019). Trauma and cultural values in the health of recently immigrated families. Journal of Health Psychology. Advance online publication. https://doi.org/10.1177/1359105319842935.
- Migration Policy Institute. (2020). Dismantling and Reconstructing the U.S. Immigration System: A Catalog of Changes under the Trump Presidency. Washington, DC. www.migrationpolicy.org/research/us-immigration-system-changes-trump-presidency.
- Sherman, C., Mendoza, M., & Burke, G. (2019, November 12). The US held a record number of migrant children in custody in 2019. Nation. Retrieved from https://www.usatoday.com/story/news/nation/2019/11/12/border-crisis-us-government-held-70-000-migrant-children-2019/2572376001/ Accessed on September 26, 2020.
- Garcini, L. M., Domenech Rodríguez, M. M., Mercado, A., & Paris, M. (2020). A tale of two crises: The compounded effect of COVID-19 and anti-immigration policy in the United States. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S230-S232. http://dx.doi.org/10.1037/tra0000775.
- Willis, O. (2020, January 7). Poor air quality caused by bushfire smoke posing serious risk for healthy people too, health experts warn. ABC Health & Wellbeing. Retrieved from https://www.abc.net.au/news/health/2020-01-07/prolonged-bushfire-smoke-creates-new-health-risks/11844934. Accessed on September 26, 2020.
- Townsend, M. J., Kyle, T. K. & Stanford, F. C. (2020). Outcomes of COVID-19: disparities in obesity and by ethnicity/race. International Journal of Obesity, 44, 1807–1809. https://doi.org/10.1038/s41366-020-0635-2.
- Owen, W. F., Carmona, R., & Pomeroy, C. (2020). Failing another national stress test on health disparities. Journal of the American Medical Association, 323, 1905-1906. doi:10.1001/jama.2020.6547.
- U.S. Department of Health and Human Services, Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act. (2020, April 11,13). Frequently Asked Questions Memo. https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf;.
- Keith, K. (2020). HHS Strips Gender Identity, Sex Stereotyping, Language Access Protections From ACA Anti-Discrimination Rule. Health Affairs, https://www.healthaffairs.org/do/10.1377/hblog20200613.671888/full/.
- Bernstein, H., Gonzalez, D., Karpman, M., & Zuckerman, S. (2019). Amid Confusion over the Public Charge Rule, Immigrant Families Continued Avoiding Public Benefits in 2019, Urban Institute, https://www.urban.org/research/publication/amid-confusion-over-public-charge-rule-immigrant-families-continued-avoiding-public-benefits-2019.
- Centers for Medicare & Medicaid Services. (2020). Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority, 85 FR 37160. https://www.federalregister.gov/documents/2020/06/19/2020-11758/nondiscrimination-in-health-and-health-education-programs-or-activities-delegation-of-authority.
- U.S. Dept. of Labor, Families First Coronavirus Response Act: Employer Paid Leave Requirements, https://www.dol.gov/agencies/whd/pandemic/ffcra-employer-paid-leave.
- Migrant Policy Institute. (2020). Immigrant Workers: Vital to the U.S. COVID-19 Response, Disproportionately Vulnerable. https://www.migrationpolicy.org/research/immigrant-workers-us-covid-19-response.
- Tobias, M. (2020, August 28). Will Foster Farms plant in California stay open despite shutdown orders? Here’s what we know. Fresno Bee. https://www.fresnobee.com/news/coronavirus/article245330465.html.
- UNICEF. (2018). Migración resiliente. Herramientas de rescate emocional para niñas, niños y adolescentes migrantes. Retrieved from https://www.unicef.org/mexico/media/1266/file/VCEMigraciónResiliente_mar2018.pdf. Accessed on September 2020.
- Lund, C., Brooke-Sumner, C., Baingana, F., Claire Baron, E., Breuer, E., Chandra, P., Haushofer, J., Herrman, H., Jordans, J., Kieling, C., Medina-Mora, M. E., Morgan, E., Omigbodun, O., Tol, W., Patel, V., & Saxena, S. (2018). Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry, 5(4):357-369. DOI:https://doi.org/10.1016/S2215-0366(18)30060-9.
- Arnetz, J., Rofa, Y., Arnetz, B., Ventimiglia, M., & Jamil, H. (2013). Resilience as a protective factor against the development of psychopathology among refugees. The Journal of nervous and mental disease, 201(3), 167.
- Gómez-Gutiérrez, A. (2019). Transmigrantes centroamericanos por territorio (s) mexicano (s): ecos de la resiliencia y la violencia. Huellas de la Migración, 4(7), 55-80.
- Servan-Mori, E., Leyva-Flores, R., Xibille, C. I., Torres-Pereda, P., & Garcia-Cerde, R. (2014). Erratum to: Migrants suffering violence while in transit through Mexico: Factors associated with the decision to continue or turn back. Journal of Immigrant and Minority Health, 16(1), 177–178. https://doi.org/10.1007 /s10903-013-9860-2.
- Lemus-Way, M. C., & Johansson, H. (2019). Strengths and Resilience of Migrant Women in Transit: An Analysis of the Narratives of Central American Women in Irregular Transit Through Mexico Towards the USA. Journal of International Migration and Integration, 1-19.
- Temores-Alcántara, G., Infante, C., Caballero, M., Flores-Palacios, F., Santillanes-Allande, N. (2015). Salud mental de migrantes centroamericanos indocumentados en tránsito por la frontera sur de México. Salud Pública de México 57, 227-233.