When thinking about immigrant children today, we are likely to picture clusters of kids crowded into dirty detention centers, scared and crying behind wire fences.¹ The zero-tolerance policy enacted in April 2018 has put a spotlight on the more than 5,400 children separated from their parents at the U.S.-Mexico border,² along with thousands more kept in detention with their families.

But the category of immigrant children is significantly larger than those caught in the turmoil at the U.S. southern border. Immigrant children, defined more broadly as all children of all immigrants living anywhere within the United States, represent 19.6 million children, nearly one-fourth of all children in the United States.^3,4 This is a heterogenous group that includes refugees, asylum seekers, recipients of the Deferred Action for Childhood Arrival policy or of special temporary status, and unaccompanied minors. The group also includes first-generation Americans who are U.S. citizens by birth—children born to immigrant parents or those living in households in which at least one parent is an immigrant⁵ (Table 1^5–7).

Immigrant children are a vulnerable group, requiring special protections under U.S. and international law.⁸ Compared with nonimmigrant children, they face additional dangers to their physical and mental health—regardless of their country of origin—that stem directly from immigration policies, including the right to asylum, detention and deportation protocols, regulation of health coverage, and access to physical and mental health care.⁹

The health of our patients is tightly linked to forces beyond biology, lifestyle, and genetics. The recognition of the role of the social determinants of health has prompted many, including the American Academy of Family Physicians (AAFP), to promote actions and activities that address these determinants. The immigration experience is now recognized as one of those social determinants.^10,11

It is time to identify and respond appropriately to what I call the political determinants of health,¹² that is, the idea that nearly all of the social determinants of health are affected by political decisions. Policy making is ultimately political, which is not necessarily a bad thing. Children have benefited, for example, from programs such as the Children’s Health Insurance Program and the Vaccines for Children Program, which are both outcomes of political wrangling that produced valuable policies. However, the recent series of specific policy decisions on immigration has produced profoundly negative physical, emotional, mental, and developmental consequences for immigrant children.

For example, the family separation policy has been associated with acute and longer term psychological, social, and health problems.^13–16 Family detention and efforts to allow indefinite detention of children¹⁷ contributed to overcrowding in detention centers. In these situations, children had no access to blankets, beds, clean water, personal hygiene products, or age-appropriate foods and conditions, and they were exposed to harsh environmental conditions such as cold temperature and continuous lights for 24 hours a day.^18–22 These conditions, as reported by lawmakers, legal representatives, and physicians who visited the facilities, have been associated with negative mental health effects such as exacerbation of trauma, fear, anxiety, and depression.^23,24 The deaths of at least seven children have been attributed to substandard conditions in immigration detention.²⁵ Detention was also associated with dysregulation of circadian rhythms, scabies, and infectious disease outbreaks.^18,26 In parts of the United States other than the southern border, the expansion and stricter implementation of deportation that removed or threatened to remove immigrant parents of children born in the United States have been associated with trauma, fear, and depression.^27,28

What can family physicians do to help immigrant children through addressing the social and political determinants of health?

We must first recognize the effects of political decisions on the health of immigrant children and inquire about how these policies are affecting our individual patients and their families. We should offer referrals to appropriate resources, including legal assistance. The American Academy of Pediatrics has created a toolkit to guide clinicians who care for immigrant children.²⁹ The toolkit covers common clinical issues, addresses access to care, reviews immigrant children’s mental health needs, and provides links to legal resources and guidance on advocacy activities.

Regarding advocacy, we can look to examples set by leaders within the AAFP who spoke up.^30,31 We can support and applaud the AAFP’s collaboration with other physician organizations to issue statements and to offer a unified voice demanding change.³² See a recent piece in American Family Physician for additional resources about patient advocacy³³ and the AAFP website for an advocacy toolkit.³⁴

We can learn from efforts by physicians and experts seeking to influence their elected officials by starting letter writing campaigns, writing op-eds, issuing public comments, and participating in rallies and demonstrations. We can be inspired by family physician colleagues such as Drs. Claudia Mercado and Patricia Lebensohn who work at the frontlines with immigrant children and their parents.^35,36

Ultimately, changing policies requires holding politicians accountable through voting. Our votes (and our patients’ votes) can determine what happens to immigrant children, how well or poorly they are treated, where they end up, and their overall health and well-being.