Bioethics Forum Essay
“If the virus doesn’t kill us, the stress and anxiety will.” Immigrants during Covid
Growing isolation, financial challenges, and disease burden during the Covid-19 pandemic threaten to worsen the mental health needs of the entire U.S. population. These challenges are heightened among immigrants with untreated chronic mental health conditions as they experience added psychological distress owing to harsh immigration policies and worsening structural barriers to health during the pandemic.
Immigrants face challenges before, during, and after their journey to the U.S. that may exacerbate or cause mental health problems. Often fleeing life-threatening situations, some encounter violence, detention, or death along their migration. Once here, many continue to experience postmigration stressors, including family separation, cultural and language barriers, and adjustment to an increasingly unwelcoming environment. The psychological impact of adapting to a new culture is associated with depression, anxiety, suicidal ideation, low-self esteem, and psychological distress among immigrants. Immigrants are less likely than nonimmigrants to use mental health services, leaving them at risk of untreated mental health conditions. Instead, they rely on work, spirituality, and the social support of family to cope. However, social distancing mandates and growing unemployment have left many without a support system to manage the growing psychological burden during the pandemic.
As an undocumented immigrant who is a recipient of Deferred Action for Childhood Arrivals (DACA), I know the psychological challenges surrounding the uncertainty about the program and my ability to remain in this country, compounded by fear of how Covid-19 would affect my family and my community.
After more than a decade of living in fear and hiding my immigration status, in 2012 I provided all my personal information to the U.S. government. In return, I was granted DACA, a two-year renewable work permit and temporary protection from deportation. DACA allowed me the safety and stability to pursue higher education. Filled with hope and the promise of a future in this country, I took classes at a community college, worked two jobs to support my family, and got a driver’s license. These opportunities would have been impossible without DACA. I graduated from college and began my training as a physician-scientist at Harvard Medical School. I was living the American dream. Then, in 2017, the Trump administration announced it was ending DACA, a decision that threatened to strip away the security and protections that formed the foundation of my new life. I was painfully reminded of my vulnerability—a warning that these protections were temporary, and the fruits of my hard work could be easily ripped away.
Several lawsuits were filed against the administration, and on June 18 the U.S. Supreme Court ruled against the decision to end the program. For now, DACA recipients are still able to apply for renewals and individuals who are eligible can submit new applications, but the ultimate fate of the program remains uncertain. While the court decided the “arbitrary and capricious” way Trump went about canceling DACA was illegal, the justices agreed that the president has the authority to end the program given the proper legal justification. It remains possible that, if re-elected, Trump could try to cancel DACA again. That possibility causes those of us working on the front lines of the pandemic stress and anxiety. It has intensified feelings of frustration and helplessness, of being unable to financially support our families and legally serve this country in a time of desperate need.
Although at times I have felt lonely and paralyzed in the face of growing uncertainty, I am reminded that most of my immigrant community faces the pandemic without the protections that I fear losing. Unlike me, weathering the pandemic at home was never an option for my father, who continued to work at a factory as cases rose. Without adequate information and protective equipment, both of my parents were infected with Covid-19 by early March. Although my parents endured a mild course of the disease, many of their co-workers and friends did not survive. Witnessing firsthand the irreversible consequences of the pandemic on my own family, I began to reach out to my local community. Through telephone interviews and virtual community meetings it became increasingly clear that my largely immigrant community carries the burden of this crisis without support, leading to worsening mental health among already vulnerable people.
I was horrified when Natalia (a pseudonym), an undocumented immigrant and activist, told me that she found a community member attempting to commit suicide in her backyard. This shocking story highlights the impact of unmet mental health needs for immigrants. Natalia volunteers distributing food to families in need. She has noticed that “people can’t pay rent and are being forced to move out. Parents can’t afford to feed their children anymore.” Ineligible for public assistance programs, undocumented immigrants have traditionally relied on charitable services. With growing demand, these resources have become increasingly scarce, and undocumented immigrants face higher risks of extreme food and housing insecurity. Unable to fulfill these basic needs, immigrant families face both the acute stress and the possible long-term behavioral health consequences on their own.
The situation is even worse in immigration detention centers. Of the estimated 30,000 individuals currently held in ICE facilities, most (61.2%) do not have a single criminal conviction. In 2018, researchers found that individuals detained at three ICE detention centers reported high levels of stress and anxiety stemming from factors including unhygienic conditions, isolation, untreated medical and mental health problems, and the uncertainty regarding their legal cases. These stressors are heightened during a pandemic that threatens mass contagion among detainees held in crowded and unsanitary facilities. According to ICE, between February and June 22, of the 8,858 detainees tested for Covid-19, more than on quarter (2,403) have tested positive. Restrictions on immigration court hearings during the pandemic will likely worsen the backlog of more than one million cases, prolonging the isolation that can have negative physical and mental health effects.
Natalia put the situation into stark relief: “If the virus doesn’t kill us, the stress and anxiety will.” If we are truly in this together, we must not let the mental health of this community, my community, fall through the cracks. Addressing the mental health needs of immigrants will take time, but there are public health, medical, and policy actions that can mitigate the consequences of Covid-19 now. There is a critical need to expand and connect immigrants to health care services that enable the necessary mental health screening and follow-up care. Health care providers caring for immigrants should become familiar with published guidelines on best practices to address the unique mental health needs of this community.
Policy changes must be made to ensure equitable access to services that could improve the mental health of immigrants. Including undocumented immigrants in federal and state Covid-19 relief programs, as has been done in California, is one appropriate step. To limit the spread of Covid-19 and prevent exposure to conditions that exacerbate mental health conditions, the federal government should consider the coordinated release of immigrants held in ICE detention centers. Longer term, our leaders must recognize the contributions of immigrants to our society, yours and mine, by creating immigration policies that respect the humanity of all people. The injustices in our health and immigration system threaten our collective health, and the capacity to overcome the pandemic as a country requires all of us working together to address these inequalities. As a medical student, I pledged to be part of this collective effort to heal and alleviate the suffering of vulnerable communities, but without permanent protection from deportation I may not be allowed to see this promise through.
Silvia Huerta Lopez is a student at Harvard Medical School.
I thank Louise P. King, MD, JD, and Margaret Sullivan, FNP-BC, DrPH, for their valuable insight and unwavering support and encouragement in writing this piece. Thank you to Yesenia Mejia, Camila Mercedes Mateo, MD, Jennifer Kasper, MD, and David Shumway Jones, MD, PhD, for their comments and suggestions. A special thanks to my family and the courageous immigrants who shared their stories with me and continue to inspire my journey in medicine.
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