Background and Literature Review
Central American immigration, immigrant detention, and psychobological effects of trauma
The investigative team embarked on this project intentionally without reading everything that has been coming out in the news, although news about family detention has been somewhat difficult to avoid. The team engaged in the research with fresh eyes, a neutral position on ICE and the Department of Homeland Security (DHS), and open minds. They were able to allow participants to direct the qualitative interviews without unconsciously influencing their narrative with prior knowledge that might have informed the questions they asked. In writing up the results, they have pored over contemporary new and literature in great detail. That this research supports the findings in the literature as well as those of other agencies such as the Lutheran Immigration and Refugee Service (LIRS) strengthens the case for considering these centers as inhumane and counter to U.S. moral values and for closing them, just as they were closed in 2009.
Central American Immigration
More Central Americans are being caught crossing the border than other populations, although statistics show that the number of apprehensions remain low, compared to peak rates in 2000 (Castillo 2014). In 2014, immigrants from Honduras, Guatemala, and El Salvador represented 40% of all apprehensions. After September 11, 2001, security conditions at the U.S.-Mexico border gradually became tighter, but immigrants continued to enter the United States in large numbers. The Central American post-war period has been marked by attacks, robberies, and kidnappings for ransom, regardless of social-class status. Thus immigrants kept crossing the Mexican and the U.S. borders, despite the fact that safety conditions for passage through Mexico are harrowing. The Central American experience of “crossing” the 3,000-mile-long journey from the isthmus to the U.S.-Mexico border is one that features threats of violence, rape, extortion, kidnapping, and death at the hands of gangs, cartels, and armed individuals who use force and fear to enforce their power over refugees on their journey north.
The massive flow of Central American immigrants to the United States was a direct result of the brutality of the Central American civil wars of the 1980s and of the toll they extracted on indigenous and peasant communities. The lack of economic opportunities, combined with the massive amount of unemployed soldiers, including counterinsurgency specialists, in these countries, led to a rapid rise in banditry, drug violence, and street crime. This unexpected factor meant that instead of enjoying greater safety as a consequence of the end of the war, most Salvadoran and Guatemalan citizens were exposed to the greatest crime wave in their history, with the added caveat that neither individual citizens nor governmental institutions had any control over these mobile, translocal, transnational groups. Within a short period of time most social sectors lost faith in their state’s capacity to control these criminal elements and began to arm themselves, pay for private security, or endorse measures to eliminate them, while trampling on civil liberties. Shootings became an everyday occurrence, even in elite restaurants, malls, and public spaces.
The scars of a violent history remain engraved in the Central American immigrant population, even if the 1980s civil war is no longer taking place — it remains as an open wound and a fearsome memory. Indeed, war traumas have been substituted by new traumas such as those inflicted during the crossing of the 3,000-mile-long journey from Central America to the U.S.-Mexico border and the daily risks of life in the United States in an anti-immigrant environment. In 2003, Arturio Arias first traced the 1980s exodus of Central Americans in the first issue of Latino Studies, where he explained the phenomenon of “originary terror,” resulting from refugees’ experiences involved in witnessing and surviving massacres during the civil war. Entering the United States primarily through California, Arizona, and Texas, Central American refugees have fanned out throughout the nation.
A significant source of anxiety and depression among detainees is the direct result of the uncertainty of not knowing where family members are or if they are still alive. Immigration authorities separate members of families from one another immediately upon apprehension. Mothers are separated from their children they are sometimes reunited and sometimes not. Fathers are separated from their families as a matter of course and either sent to a different detention facility or deported. Families often do not know where their members have been sent. Mothers are threatened with the loss of their children if they hesitate to comply with ICE orders or if they report suffering from mental health issues children are used as a means of social control. The term “family” detention is a peculiar misnomer.
The issue of immigrant detention is framed by national and policy reaction to the events of September 11, 2001. Prior to this event the Supreme Court had ruled that immigrants could not be detained indefinitely without due process. The Court reversed itself in 2003, ruling that immigrants could be detained in facilities indefinitely without the benefit of a hearing to establish their security risk or flight risk. This ruling established the legality of the Guantánamo Bay facility but it also opened the door to contemporary immigrant and family detention practices in which mothers and children, even families who have an order for release, are held in detention facilities for months (Greenhouse 2003 Mehta 2015 Swarns 2003).
To preserve children’s well-being, they should not be held in detention facilities. The Flores class-action decision in 1997 set forth the conditions under which children could or could not be detained in an immigrant facility: children may not be detained in a “secured,” that is prison-like, facility such as Dilley or Karnes, where they are not free to leave at any time. According to the Flores decision, children must be released immediately into the care of family members or legal guardians, and such individuals must be identified and located without delay. If the child’s guardian was also detained, such as is the case of “family” detention, that guardian must also be released to be able to care for the child. The language of the ruling reads, “If a relative who is not in detention cannot be located to sponsor the minor, the minor may be released with an accompanying relative who is in detention.” Thus the ruling is very clear: family detention is against the law according to the Flores decision (Planas & Foley 2015).
The Department of Justice was sued on behalf of Flores to uphold the terms of the agreement when large numbers of Central American children, accompanied and unaccompanied, began to be apprehended crossing the border in the summer of 2014. Family detention, which had been abolished in 2009 as inhumane, was revived to help an overwhelmed ICE manage the numbers of undocumented immigrants, of whom up to 99% were asylum seekers with special protections (Lutheran Immigrant and Refugee Services and Women’s Refugee Commission 2014). In July 2015, Judge Dolly M. Gee of the U.S. District Court for the Central District of California issued an order that the administration comply with Flores, noting that evidence from the past year showed that family detention violated these terms. In particular, the judge ordered that children should be processed within five days of apprehension, or, if DHS is incapable of processing people that quickly, within approximately 20 days, but only if they are in the care of a relative in a nonsecure, licensed facility (Preston 2015). However, the government is vigorously protesting the Flores decision, has asked the court to rescind it (Human Rights First 2015 The Associated Press 2015), and in September 2015 filed an appeal.
As one assesses the mental health and well-being of refugee women and children, the use of for-profit prison contractors is of particular concern. As early as the Clinton administration, immigrant detention facilities have been outsourced to private prison contractors (Kirkham 2012). Nine out of ten detention centers are privately run (Plana 2015). The amount of money generated by immigrant detention is staggering — a $74 billion enterprise — and there are many participants in this “economic constituency” (Karlin 2014). These include private prison contractors, prison guards, police, detention center staff, and politicians who receive campaign donations (Shen 2012). Private prison contractors profit enormously from the criminalization of immigration (Takei 2014), which they consider a “growth” industry in that profits depend on an increasing number of immigrants being detained and warehoused in privately run detention facilities. The story of family detention is nothing less than a story of “treating citizens like revenue sources” (Krayewski 2015).
One immediately sees that Latino bodies have been transformed into cash, and the misfortune of the vulnerable leads to enormous profits for private prison contractors. This relationship dehumanizes refugee families, treats them as criminals rather than asylum seekers, and could mute public outcry and oversight of their abuse.
The use of for-profit prison contractors in immigration facilities contributes to a total lack of transparency, as these corporations are not subject to Freedom of Information Act transparency law (Gilna 2013), and do not have to provide the public with any information regarding their activities. When considering the mental health needs of refugee families, this is extremely troubling. A lack of transparency and oversight can lead to abuse and neglect. We see this as an egregious problem that impinges not only on the rights of immigrants but also on the rights of taxpayers to know how their tax dollars are being used.
There have been many reports of abuse, medical neglect, and incompetence there have been sexual assaults and rape of female inmates, criminal neglect of birthing mothers in which the babies died (e.g., Participant 14) there was a case of a disabled man being dumped out of his wheelchair by a guard (Wofford 2014) there have been suicides, which are the cruelest indicator of incompetence in so many ways, not least of which are the lack of mental health care, understaffing, and the lack of oversight that allowed despondent people the opportunity to hang themselves (Gilna 2013). There has been falsified records and billing (Wofford 2014). Clearly, outsourcing without oversight leads to abuse.
Psychobological Effects of Trauma
Pedersen et al. (2008) examined the long-term sequelae of political violence in their study of the Peruvian Maoist group Sendero Luminoso or Shining Path (Pedersen, Tremblay, Errazuriz, & Gamarra 2008). They found that those who suffered the most were rural Quechua speakers living in poverty conditions, subjected to terror and death from the Shining Path on one side and to police brutality on the other. These conditions are similar to those experienced by Central American refugees who are caught between violent gangs and complicit police. Women and
civilians with low social capital, such as children and low-income people, suffer the most from political and community violence (Harpham, Grant, & Rodriguez 2004 Khamis 1998 Stockdale et al. 2007).
Negative mental health outcomes and subsequent increased risk
The World Health Organization reports that depression accounts for 4.4% of the global disease burden (a loss of 65 million disability adjusted life years, or DALYs), a morbidity rate comparable to heart disease, diarrheal diseases, or asthma and chronic obstructive pulmonary disease combined (Chisholm, Sanderson, Ayuso-Mateos, & Saxena 2004). The prevalence of depression among adults in the United States is approximately 9.6% (CDC 2014). Persons most at risk for suffering depression are women (10.2%), Hispanics (11.7%), African Americans (12.9%), and the unemployed or uninsured. The Central American refugee population with whom this report is concerned thus are at risk for negative mental health outcomes through several known risk factors. However, there has been little research regarding the mental health profile of Central American refugees, a gap that this report only begins to address.
Depression, anxiety, and post-traumatic stress may lead to physical problems and chronic illness among individuals who do not receive appropriate mental health care. Behavioral health accounts for a significant part of global disability burden: half of U.S. adults will suffer a mental health issue in their lifetimes, and 27% will suffer a substance abuse problem. Refugees who have been through horrendous experiences are at significant risk for depression, anxiety, and post-traumatic stress. If not treated appropriately, these conditions may result in higher health- care cost burden down the line, in addition to substantial human suffering.
Depression and chronic illness (O’Connor et al. 2015)
The refugee experience, with associated depression, anxiety, and post-traumatic stress, puts individuals at increased risk for comorbid chronic physical illnesses that are known health issues among Hispanics in general, such as diabetes, cardiovascular disease, obesity and metabolic syndrome, and asthma. There is considerable evidence for the positive association between depression and chronic illness and for the increased risk of mortality from chronic illness in the presence of comorbid depression and multimorbid health status that includes depression (Bajko et al. 2012 Capuron et al. 2011 Capuron et al. 2008 Chapman, Perry, & Strine 2005 Chien, Wu, Lin, Chou, & Chou 2012 Cutshaw, Staten, Reinschmidt, Davidson, & Roe 2012 Eaton 2002 Nancy Frasure-Smith & Lesperance 2008 N. Frasure-Smith et al. 2007 N. Frasure-Smith, Lesperance, Irwin, Talajic, & Pollock 2009 Green, Fox, Grandy, & Group 2012 Hartley et al. 2012 Meng, Chen, Yang, Zheng, & Hui 2012 Nguyen et al. 2012 Niranjan, Corujo, Ziegelstein, & Nwulia 2012 Pereira, Barreto, & Passos 2009 Raji, Reyes-Ortiz, Kuo, Markides, & Ottenbacher 2007 Rose, Peake, Ennis, Pereira, & Antoni 2005 Viscogliosi et al. 2013 Wu, Chien, Lin, Chou, & Chou 2012).
Chapman et al. surveyed the literature on the associations between depression and chronic diseases, including asthma, arthritis, cancer, cardiovascular disease, diabetes, and obesity they projected that by 2020 depression would be second only to cardiovascular illnesses in the global burden of disease (Chapman et al. 2005). A bidirectional relationship between depression and cardiovascular disease has been observed, with mortality rates higher in depressed patients (Nemeroff & Goldschmidt-Clermont 2012). Individuals suffering from depression are more than one and a half times more likely to develop heart disease, a risk that is more significant than the risk from passive cigarette smoke. Depressed individuals are four times more likely to suffer a myocardial infarction than healthy individuals, and depression interferes behaviorally with compliance to drug therapies and with rehabilitative and diet regimens after a cardiac event (Bautista, Vera-Cala, Colombo, & Smith 2012). Depressed individuals are twice as likely to have a stroke within 10 years, and having a stroke or receiving a cancer diagnosis or diagnosis of a chronic illness increases the risk for developing comorbid depression (Kang et al. 2012). Research suggests a relationship between hypertension and depression (Ginty, Carroll, Roseboom, Phillips, & de Rooij 2013). Conversely, having a chronic illness negatively affects self-perception of quality of life, a risk factor for depression (Cutshaw et al. 2012).
Diabetes in particular has been positively associated with higher rates of depression in a bidirectional manner (Johnson et al. 2012 Katon et al. 2010 Rustad, Musselman, & Nemeroff 2011). Depression is commonly comorbid with diabetes and occurs among patients with diabetes at rates that are 30–40% higher than the general population, and two to three times higher than among healthy controls (Eaton 2002 Johnson et al. 2012). Psychosocial relationships can both mitigate or contribute to depression, exerting significant influence on outcomes among patients with diabetes (Arigo, Smyth, Haggerty, & Raggio 2014 Sussman et al. 2014). Patients with comorbid depression and diabetes are at increased risk of negative health outcomes, including risk factors such as poor self-care, higher rates of complications, and higher rates of morbidity (Gask, Macdonald, & Bower 2011 Gravely-Witte, De Gucht, Heiser, Grace, & Van Elderen 2007 Katon et al. 2010). The prevalence of depression is twice as high in individuals suffering from diabetes as in healthy individuals (Anderson, Freedland, Clouse, & Lustman 2001 Eaton 2002). Among individuals with a “triad” or multimorbid condition of diabetes, hypertension, and obesity, 16.5% also reported suffering from depression (Green et al. 2012).
Depression is associated with development of metabolic syndrome among women under 40, and a reciprocal relationship between obesity and depression has been observed (Capuron et al. 2011). Analysis of the immune response shows a bidirectional relationship between metabolic syndrome and depression through elevated levels of inflammatory markers in both conditions, establishing that both metabolic syndrome and depression are associated with dysfunctional immune response (Capuron et al. 2011 Capuron et al. 2008). Chronic stress and depression elevate levels of inflammatory cytokines, which in turn increase the risk of coronary artery disease (N. Frasure-Smith et al. 2007 N. Frasure-Smith et al. 2009). The presence of depression and other mental illnesses may contribute to the development of chronic illnesses chronic illness may be a risk factor for the development of depression (Chapman et al. 2005). This considerable body of evidence suggests changes in policy with regard to the detention of refugees and asylum seekers that detention may increase the risk for negative mental health outcomes, including depression, in already traumatized and depressed individuals should influence policy decisions about immigrant detention. In other words, detention may be making people chronically ill and for this reason, if for no other, the policy should be revisited.
Since four out of five leading causes of death among Hispanics are chronic illnesses that the evidence has shown are frequently comorbid with depression (Cutshaw et al. 2012), recognizing and addressing depression among Central American refugees is particularly relevant. The population of Central American refugees in this report, with high rates of depression and anxiety, are therefore at significant risk for developing chronic illnesses. In addition to human suffering, the potential for increased health-care costs should not be overlooked. It is recommended that the mental health of immigrants and refugees be addressed as a policy issue, and the conditions in which refugees are detained should be significantly improved so as not to further contribute to negative outcomes among already depressed and traumatized human beings.
According to the DSM-IV-TR (APA 2000), post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by exposure to a single traumatic event, and presenting with a number of symptoms such as recurrent intrusive negative thoughts disturbing dreams that may include the traumatic event and reexperiencing the event through unconnected, happenstance reminders (DSM-IV-TR code: 309.81 ICD-10 code: F43.1,F62.0). Many of the participants in this study reported significant and classic signs of post-traumatic stress, notably recurrent and intrusive thoughts, flashbacks, nightmares, hypervigilance, and sleep disturbances. PTSD may also present with a number of similar clinical phenotypes such as depression, anxiety disorder, and psychosis. Although PTSD has begun to be recognized as a growing problem in civilian communities and not solely a problem resulting from military deployment, the effects of psychological trauma and concomitant stress-related disorders are only recently being understood.
Trauma can result from a number of circumstances. Traumatic events can include armed conflict, civil war and genocide, accidents, the diagnosis of serious illness such as cancer, and witnessing or experiencing violent acts such as rape or domestic violence. Participants reported suffering as many as 15 or 20 of these types of events, both in the sending country and during travel to the United States. Children are at particular risk for developing long-term problems. Childhood trauma, such as the kinds of traumatic events the children in our study reported suffering, has been shown to put adults at risk for the subsequent development of adult-onset PTSD through re-traumatization via other negative stimuli (Binder et al. 2008).
Research has shown that in PTSD and stress-related disorders, for which Central American refugees are at risk, repetitive activation and deactivation of the hypothalamic–pituitary–adrenal axis (HPA), which controls mood, stress reactions, and the immune system, disrupts its usual functioning. Sufferers lose the ability to return to normal because this biological function becomes oversensitive (Rohleder, Joksimovic, Wolf, & Kirschbaum 2004). PTSD sufferers also may have preexisting vulnerability factors such as higher baseline cortisol levels (Flory & Yehuda 2015 Yehuda et al. 2014) or naturally high levels of glucocorticoid receptors prior to trauma exposure (Zuiden et al. 2011). Enhanced negative feedback sensitivity (Yehuda 1996) also puts trauma survivors at risk for chronic inflammatory response. Research on the biology of PTSD is challenging because PTSD is characterized by the experience of a traumatic event, which cannot be clinically staged or replicated however, observational research can be conducted. Research among Central American refugees is warranted for the development of just and effective policy, because the mental health and psychobiological outcomes of the refugee experience are poorly understood and distinct from that of immigrants. Despite this, refugees are frequently treated in the same way as immigrants from a policy perspective notwithstanding their increased risk of negative health outcomes.
Placing a policy focus on ameliorating symptoms of PTSD, anxiety, depression, and stress- related disorders suffered by Central American refugees and asylum seekers is important because the long-term physical effects of these conditions increase the risk of metabolic disorders such as diabetes, obesity, atherosclerosis, and heart disease as well as cancer (Black 2006 Nowotny et al. 2010 Reagan, Grillo, & Piroli 2008) and the long-term health effects and health-care costs associated with these illnesses. For example, up to 40% of U.S. military veterans with PTSD suffer from a comorbid metabolic disorder (Heppner et al. 2009 Rasmussen, Crager, Baser, Chu, & Gany 2012 Rasmussen, Smith, & Keller 2007). Elevated IL-6, an inflammatory cytokine positively correlated with stress, has been observed in Hispanic breast cancer patients (Erdei et al. 2010). Central American refugees are disproportionately represented in terms of exposure to stress and trauma because of social conditions in their home countries as well as traumatic experiences during travel to the United States, including extortion, kidnapping, fear of being murdered, and a harsh geography. As refugees and asylum seekers, these individuals have a right to fair treatment under international law and, at the very least, a right to administrative conditions and policy that do not exacerbate the trauma and health risks they have already suffered.