Immigration across the US-Mexico border has increased dramatically since 2014.1  The current US immigration system is overwhelmed and ill equipped to handle such volumes, leading to a major disruption in medical care and services granted to refugee and immigrant children.2  More specifically, the health of these children is of dire concern because of overcrowded facilities with infectious disease exposures, insufficient access to medical services for children with underlying medical conditions, and poor support for the consequences of the challenging travel from their country of origin. Consequently, within the past year alone, at least 6 pediatric deaths have occurred while in US Customs and Border Protection (CBP) detention centers.3  Since their stories were publicized, there has been a growing concern raised both by the general public2  and the American Academy of Pediatrics1  regarding the treatment of children at these facilities.

On further review of the workflow involved in processing immigrants within these centers, a new issue has arisen, which appears to be both prevalent and underreported.4  Several news outlets released stories about detained children and adults having their medications confiscated.2,4  Specifically, medications critical for the management of chronic conditions, such as insulin, steroids, and antiepileptics, were permanently removed from detainees while at these facilities without proper replacement.4  This represents both a human rights violation and a breach of federal policy. CBP policy clearly states that detainees possessing non–US-prescribed medications will have their medications “validated by a medical professional, or should be taken in a timely manner to a medical practitioner to obtain an equivalent US prescription.”5  Unfortunately, although this policy is clearly defined, it is not always followed.4  The 2 cases below were encountered ∼2000 miles from McAllen, Texas, where this problem was first reported. These children represent clear examples of the severe detrimental effects of medication confiscation on both the patient and the health care system that may not be noticed nor reported on a national level.

A school-aged girl* with a history of mild-intermittent asthma immigrated from Central America 2 months before presenting to a local emergency department in severe status asthmaticus. She was transferred to our institution and admitted to the PICU with the need for continuous albuterol treatment because of severe refractory bronchospasm. She was also found to have a right middle lobe infiltrate on a chest radiograph and a reverse transcription–polymerase chain reaction result positive for human metapneumovirus. The family reported that the patient’s albuterol inhaler was taken away from her at a detention center soon after crossing the US-Mexico border, and no replacement was provided. When the patient had developed respiratory symptoms 3 days before her presentation, she was unable to manage her symptoms at home without her albuterol inhaler. She ultimately became sicker, thus prompting her visit to the emergency department and subsequent admission to our PICU.

A 7-year-old boy with a medical history of moderate-persistent asthma was admitted to the same PICU because of severe status asthmaticus in the setting of influenza B infection identified by reverse transcription–polymerase chain reaction respiratory viral panel. He had been detained at a CBP facility for 2 days before being released and then traveled several thousand miles northeast to stay with his mother’s extended family. While he and his mother were detained, the boy’s albuterol inhaler was confiscated, and a replacement was not provided. This child had developed respiratory symptoms 2 days after his release, and 1 week after arriving at his family’s home, he rapidly deteriorated. The family brought him to a local emergency department, and he was subsequently transferred to our PICU.

In the cases described above, the confiscation and nonreplacement of these children’s medications at CBP detention centers likely contributed to their severe presentations. These cases illustrate the detrimental consequences of CBP policy breaches from both a clinical and an economic standpoint. The unlawful removal of medications increases the vulnerability of children with chronic medical conditions, and this in turn creates an unnecessary resource burden on medical centers throughout the United States. These cases represent an emerging problem for our country’s health care system and a new focus for pediatricians.

Pediatricians encountering children in similar positions may advocate for them in several ways. The resources detailed below were those that the authors personally used and found useful. First, pediatricians may report these violations to CBP through the CBP Information Center Web site (Table 1, item 1). CBP responded to our report by assigning a local special agent from the CBP Office of Professional Responsibility to investigate our case. Second, pediatricians may contact the Department of Homeland Security (DHS) Office of Civil Rights and Civil Liberties (Table 1, item 2) and the DHS Office of the Inspector General (Table 1, item 3) to report these incidences. Both of these offices investigate human rights violations that take place while in DHS custody. Of note, Child Protective Services lacks jurisdiction in cases of child maltreatment while in federal facilities and thus were unable to assist in our cases.

TABLE 1

Resources for Physicians

1. US Customs and Border Protection Information Center 
 • Follow instructions on Web site to submit a complaint: https://help.cbp.gov/app/home/noIntercept/1 
2. DHS Office of Civil Rights and Civil Liberties 
 • Review of the office’s authority: https://www.dhs.gov/compliance-branch 
 • Information on how to file a complaint: https://www.dhs.gov/file-civil-rights-complaint 
 • Copies of the complaint form in multiple languages: https://www.dhs.gov/publication/file-civil-rights-complaint# 
3. DHS Office of the Inspector General 
 • Review of the Office’s mandate: https://www.oig.dhs.gov/about 
 • Online portal for reporting violations: https://hotline.oig.dhs.gov/#step-1 
4. Find your local representatives and senators 
 • https://www.govtrack.us/congress/members 
5. Young Center for Immigrant Children’s Rights 
 • info@theyoungcenter.org 
6. Keeping Families Healthy 
 • This program is unique to our area. We encourage others to seek similarly modeled programs in their own communities: https://medicalhomeinfo.aap.org/practices/Pages/Keeping-Families-Healthy.aspx 
1. US Customs and Border Protection Information Center 
 • Follow instructions on Web site to submit a complaint: https://help.cbp.gov/app/home/noIntercept/1 
2. DHS Office of Civil Rights and Civil Liberties 
 • Review of the office’s authority: https://www.dhs.gov/compliance-branch 
 • Information on how to file a complaint: https://www.dhs.gov/file-civil-rights-complaint 
 • Copies of the complaint form in multiple languages: https://www.dhs.gov/publication/file-civil-rights-complaint# 
3. DHS Office of the Inspector General 
 • Review of the Office’s mandate: https://www.oig.dhs.gov/about 
 • Online portal for reporting violations: https://hotline.oig.dhs.gov/#step-1 
4. Find your local representatives and senators 
 • https://www.govtrack.us/congress/members 
5. Young Center for Immigrant Children’s Rights 
 • info@theyoungcenter.org 
6. Keeping Families Healthy 
 • This program is unique to our area. We encourage others to seek similarly modeled programs in their own communities: https://medicalhomeinfo.aap.org/practices/Pages/Keeping-Families-Healthy.aspx 

In addition, pediatricians should feel empowered to work with representatives in congress and their local districts (Table 1, item 4). We have already seen instances in which members of our government have taken on this issue. Congresswoman and pediatrician, Kim Schrier, took note of this injustice and wrote a letter to the DHS and the Department of Health and Human Services to demand answers and accountability.6  Additionally, Representative Raul Ruiz proposed the “Humanitarian Standards for Individuals in Customs and Border Protection Custody Act,” which would ensure that a “detainee may not be denied the use of necessary and appropriate medication for the management of the detainee’s illness.”7  This bill (H.R. 3239) passed the house on July 25, 2019, and is now up for consideration by the senate. Pediatricians should consider lobbying their senators to support this bill.

Moreover, there are pro bono law firms and advocacy groups that work to protect immigrant populations. Specifically, The Young Center for Immigrant Children’s Rights, a human rights advocacy group composed of attorneys, social workers, and volunteers appointed by the Department of Health and Human Services to advocate for immigrant children, has volunteered to be a point of contact for physicians encountering similar positions (Table 1, item 5).

Finally, we encourage pediatric practitioners to investigate local resources available to patients on a case-by-case basis. Pediatricians can work with their institution’s and community’s social workers and case managers to address families’ individual needs. For example, these patients were referred to a local patient navigation program called Keeping Families Healthy (Table 1, item 6). Facilitating access to a medical home for immigrant children is a simple and practical method to provide timely access to medical care and appropriate follow-ups within the community.

All immigrant children deserve basic access to medical care, and this includes availability of medications that are crucial for their health maintenance.1  The confiscation of essential medications at border detention centers is one of many injustices imposed on detained children and, as illustrated in this article, is in clear violation of both the American Academy of Pediatrics and CBP policies. We believe we have a moral and ethical obligation to publicly condemn these practices. Protecting disadvantaged populations in our communities is inherently the duty of all physicians, especially pediatricians, who are responsible for our most vulnerable patients: our children.

Dr Halevy-Mizrahi drafted the initial manuscript; and both authors reviewed and revised the manuscript, were involved in the care of the patient cases reviewed in this manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

*

Multiple attempts were made to obtain consent from the patient’s caregivers for publication of this case, but the family had suddenly departed from their home as indicated by their sponsor and were now unreachable. All identifiers were removed from this case as to maintain this child’s anonymity.

FUNDING: No external funding.

     
  • CBP

    Customs and Border Protection

  •  
  • DHS

    Department of Homeland Security

1
Linton
JM
,
Griffin
M
,
Shapiro
AJ
;
Council on Community Pediatrics
.
Detention of immigrant children
.
Pediatrics
.
2017
;
139
(
5
):
e20170483
2
Fink
S
,
Dickerson
C
.
Border patrol facilities put detainees with medical conditions at risk.
The New York Times. Available at: https://www.nytimes.com/2019/03/05/us/border-patrol-deaths-migrant-children.html. Accessed November 4, 2019
3
Hennessy-Fiske
M.
Six migrant children have died in U.S. custody. Here’s what we know about them. Los Angeles Times. Available at: https://www.latimes.com/nation/la-na-migrant-child-border-deaths-20190524-story.html. Accessed November 4, 2019
4
Dickson
C.
Border Patrol is confiscating migrant kids’ medicine, U.S. doctors say. Yahoo News. Available at: https://news.yahoo.com/border-patrol-is-confiscating-migrant-kids-medicine-us-doctors-say-225354608.html. Accessed November 4, 2019
5
Kerlikowske
RG
.
National Standards on Transport, Escort, Detention, and Search
.
Washington, DC
:
US Customs and Border Protection
;
2015
6
Congresswoman Kim
Schrier
.
Rep Schrier demands answers about children being held in Vans and having life-saving medicine confiscated.
Press release. Available at: https://schrier.house.gov/media/press-releases/rep-schrier-demands-answers-about-children-being-held-vans-and-having-life. Accessed November 5, 2019
7
GovTrack
. H.R. 3239: humanitarian standards for individuals in customs and border protection custody act.
2019
. Available at: www.govtrack.us/congress/bills/116/hr3239/text. Accessed November 4, 2019

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.