• ACLU

Neither Safety nor Health: How Title 42 Expulsions Harm Health and Violate Rights

Updated: Nov 4, 2021

By PHR staff members Kathryn Hampton, MSt, MA, senior officer, Asylum Program; Michele Heisler, MD, MPA, medical director; and Cynthia Pompa, Asylum Program officer; and Alana Slavin, medical student at the University of Michigan Medical School.

Migrant families being monitored by a Border Patrol officer at a border crossing bridge.

Full Report (English)

PHR-Report-United-States-Title-42-Asylum-Expulsions-July-2021.pdf
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Executive Summary (Spanish)

PHR-Title-42-expulsions-report_July-2021_-Spanish-Exec-Summary-FINAL
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Executive Summary


Toward the beginning of the COVID-19 pandemic in March 2020, the Trump administration overrode the objections of public health experts at the U.S. Centers for Disease Control and Prevention (CDC) and compelled the CDC to issue an order under Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act that closed the border to migrants and asylum seekers.[1] The government used public health as a pretext to summarily expel children and adults seeking refuge at the U.S. border more than 980,000 times,[2] while at the same time allowing other types of travelers to continue to cross the border with no testing or quarantine requirements. Public health experts strenuously objected to the ban, pointing out the lack of epidemiological evidence for only banning this category of entrants to the United States while keeping the borders open to other travelers. A letter from public health experts in July 2021 reiterated that the latest scientific knowledge regarding transmission of the virus that causes COVID-19 did not support expulsion as a public health measure, and thus that the order undermined trust in the CDC itself as a scientific body.[3]


Nevertheless, six months into the Biden administration, the U.S. government continues to expel families and adults to countries where they face severe harm and persecution, violating their rights and failing to safeguard public health. The Biden administration also continues to carry out chaotic border expulsions that perpetuate family separation and further traumatize an already vulnerable population.


In May 2021, a Physicians for Human Rights (PHR) research team conducted interviews in Tijuana and Ciudad Juárez, Mexico with 28 asylum seekers who had been expelled under the Title 42 order, and with six health care workers providing services to migrants. The team sought to document people’s experiences during expulsion, including family separation, the actions of U.S. and Mexican government officials during the expulsion process, and the physical and mental health impacts of expulsion and family separation. PHR researchers used validated Spanish-language screening tools to screen participants for mental health symptoms, including the PCL-5 Civilian scale for post-traumatic stress disorder (PTSD) symptoms, and the Hopkins Symptom Checklist (HSCL25) for anxiety and depression symptoms.

“I cannot go back to my country. I cannot live there due to the violence. I cannot live in Mexico due to the violence. Where am I supposed to go?” 36-year-old woman from Honduras

Almost all the people interviewed came to the border to seek asylum in the United States due to gang violence or domestic violence in their home countries. Families reported repeated crossings, often in dangerous conditions – in flimsy rafts, wet and cold, carrying their children, sometimes injured, sometimes with smugglers who abused, robbed, or extorted them – in their desperation to find refuge in the United States. When asked if they feel safe in Mexico, all but one of the asylum seekers interviewed said that they did not feel safe. People told PHR researchers that they had been assaulted, kidnapped, extorted, and subjected to physical and sexual violence in Mexico. Interviewees reported that they did not have access to state protection from Mexican authorities, and several were even robbed or extorted by Mexican authorities after they were expelled from the United States.


Interviewees reported that U.S. officials rebuffed all their attempts to seek asylum in the United States. Furthermore, all the asylum seekers interviewed described gratuitously cruel and inhumane treatment at the hands of the U.S. government, including physical and verbal abuse by U.S. officials, inhumane detention conditions, active deception about their expulsion and the whereabouts of their family members, and unsafe returns that put people at heightened risk of harm.


Although the Title 42 order is characterized by the Biden administration as a public health policy, every aspect of the expulsion process, such as holding people in crowded conditions for days without testing and then transporting them in crowded vehicles, increases the risk of spreading and being exposed to COVID-19.

“I begged them over and over not to separate me from my family. I thought they would not separate us because Biden said he would not separate families, but they separated me from my partner and child.” 32-year-old man from El Salvador

The psychological effects of expulsions and family separation were also profound. Of the 26 participants who were administered validated screening tools, 25 (96 percent) screened positive for at least one mental health diagnosis; 25 (96 percent) screened positive for at least two disorders; and 23 (88 percent) screened positive for PTSD, anxiety, and depression. Of the 26 who were administered the survey, 23 people (88 percent) screened positive for PTSD related to the events leading to family separation, 25 (96 percent) screened positive for depression, and 24 (92 percent) screened positive for anxiety.


U.S. border officials not only refused to provide basic information to those they detained and expelled, they also frequently deceived and actively provided false information to asylum seekers. Sixteen interviewees reported not receiving information related to their expulsion. Ten interviewees reported being intentionally deceived by immigration officials, particularly during the expulsion process. Even more cruelly, U.S. officials deceived people about being reunited with family members, while, in reality, they were separating them.


Under the Biden administration, families continue to be separated, as some family members are permitted to enter the United States, while others are expelled. Of those we interviewed, 11 people were forcibly separated from family members by border officials. A further eight people were separated from family members they traveled with who were not their biological children, but for whom they were the primary guardian, such as younger minor siblings or nieces and nephews. These separations took place without any consideration of the needs or vulnerabilities of family members, or the age of the children.


The interviewees described the profound impact that family separation has had upon children in their family. A wide array of symptoms was described, including excessive crying, disturbed sleep, and loss of developmental milestones such as resuming bed wetting. Eleven interviewees stated that their children were not eating and had lost significant weight due to the stress of family separation.


People described an impossible situation, where they were unsafe in their own country, unsafe in Mexico, and yet unable to seek safety at the U.S. border. Public health experts have already outlined detailed recommendations on effective and evidence-based public health measures for the U.S. government to safely process families, children, and adults at the border, such as COVID-19 testing, masking, social distancing, and quarantining.[4] These measures must be implemented urgently. Every day that the Title 42 order continues to expel asylum seekers is another day that the U.S. government is harming people’s health and violating their human rights.

People seeking asylum living in tents in Mexico, because of Remain In Mexico or MPP.

Nearly all the asylum seekers interviewed by PHR said they did not feel safe in Mexico, and many reported being assaulted, kidnapped, extorted, and subjected to physical and sexual violence after being expelled there. Parents said they feared their children would be recruited or raped by gangs. Photo: Lizbeth Chávez for Physicians for Human Rights


A 22-year-old Guatemalan mother holds her sleeping child while being interviewed about her expulsion from the United States while seeking asylum, after being misled by border agents.

A 22-year-old mother from Guatemala reported to PHR researchers Alana Slavin and Cynthia Pompa. that U.S. border agents deceived her during the expulsion process, telling her she was being reunited with family in the United States while, in reality, agents were expelling her to Mexico. Photo: Lizbeth Chávez for Physicians for Human Rights


An asylum seeker waits at a shelter in Tijuana

An asylum seeker waits at a shelter in Tijuana, Mexico.Photo: Lizbeth Chávez for Physicians for Human Rights


Introduction


Toward the beginning of the COVID-19 pandemic in March 2020, the Trump administration overrode the objections of experts at the U.S. Centers for Disease Control and Prevention (CDC) and compelled the CDC to issue an order under Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act that closed the border to migrants and asylum seekers.[5] While using the pretext of stemming the spread of the coronavirus to keep out immigrants, the administration allowed many other types of travelers to continue to cross the border, and no testing or quarantine requirements for these travelers were instituted. Under the Title 42 ban, the U.S. government has violated federal and international law by summarily expelling children and adults seeking refuge at the U.S. border more than 980,000 times.[6] Over that same period, from April 2020 to March 2021, the United States admitted almost 96 million people at its land borders, including pedestrians as well as car, bus, and train passengers.[7] Public health experts have strenuously objected to the ban on border crossing to asylum seekers under public health pretexts, pointing out the lack of epidemiological evidence for only banning this category of entrants to the United States while keeping the borders open to other travelers. They outlined evidence-based processes that U.S. border officials could follow to process asylum seekers while protecting public health.[8]


Nevertheless, six months into the Biden administration, the U.S. government continues to expel families and adults to countries where they face severe harm and persecution, violating their rights and failing to safeguard public health. Despite calling Trump’s family separation policies at the border “abhorrent” and the family separation policy “criminal,”[9] the Biden administration continues to carry out chaotic border expulsions that perpetuate family separation and further traumatize an already vulnerable population. Some family members and relatives are directly separated from one another by U.S. officials. In other cases, parents, knowing that their children are not safe where they are, make the heartrending decision to send their children across the border alone in the hope that they will find protection as unaccompanied children.


In May 2021, a Physicians for Human Rights (PHR) research team conducted interviews in Tijuana and Ciudad Juárez, Mexico with 28 asylum seekers who had been expelled under the Title 42 order, and with six health care workers providing services to migrants. The team sought to document people’s experiences during expulsion, including family separation, the actions of U.S. and Mexican government officials during the expulsion process, and the physical and mental health impact of expulsion and family separation. The investigation exposed wrongful expulsions, physical and verbal abuse by government border officials during the expulsion process, and the trauma and health harms caused by this policy.

Child in mask holds her parent's hand. Border Patrol van is in the background.

Background


Trump Administration Issues the Title 42 Order


On March 20, 2020, the U.S. Department of Health and Human Services issued an emergency Interim Final Rule under a provision of Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act. The public health law grants authority to the director of the U.S. Centers for Disease Control and Prevention (CDC) to “prohibit … the introduction” of individuals that pose a “serious danger of the introduction of disease into the United States.”[10] Based on that authority, former Trump-appointed CDC director Robert Redfield simultaneously issued an order to suspend the “introduction” of noncitizen individuals in “Coronavirus Impacted Areas” who would enter the United States by land from Mexico or Canada, and who would be “introduced into a congregate setting” at a port of entry or in a Border Patrol station.[11] The order authorized U.S. Customs and Border Protection (CBP), which includes U.S. Border Patrol agents, to summarily expel nearly all migrants and asylum seekers, including children, arriving at the U.S. border. The Trump administration claimed that this was a necessary response to the COVID-19 pandemic and essentially barred asylum at the border, achieving a long-desired goal.[12]


The initial order was issued by the CDC for a period of 30 days and was extended indefinitely on May 19, 2020 by former CDC director Redfield. He stated that, “[The amended Order] shall remain in effect until I determine that the danger of further introduction of COVID-19 into the United States has ceased to be a serious danger to the public health.”[13]


Expulsions Under Title 42 for Unaccompanied Children Halted after Legal Challenges


In June 2020, civil and human rights groups challenged the expulsion of unaccompanied children under the Title 42 order. The groups argued that the Title 42 order is an unprecedented and unlawful invocation of the 1944 Public Health and Service Act that has resulted in the removal of migrant children without due process, violating the Trafficking Victims Protection Reauthorization Act, U.S. immigration laws, and international protections.[14] In November 2020, after expulsions of at least 9,000 children to dangerous settings,[15] a federal judge issued a preliminary injunction and ordered the Trump administration to stop the expulsion of unaccompanied children, ruling that the 1944 Act does not allow for expulsions.[16] In early February of 2021, the Biden administration said it was not its policy to expel unaccompanied children arriving at the border, confirmed by a CDC order in July 2021.[17] However, Biden only directed officials to review whether termination of the entire policy was necessary, while continuing to expel families and adults.[18]


Lack of Public Health Rationale


Since the inception of the Title 42 order, public health experts have stressed the lack of a valid public health rationale for denying admission to people based on immigration status and repeatedly called on the Trump administration and the CDC to rescind the order.[19] A letter from public health experts in July 2021 reiterated that the latest scientific knowledge regarding transmission of the virus that causes COVID-19 did not support expulsion as a public health measure, and thus that the order undermined trust in the CDC itself as a scientific body.[20] Public health experts have also highlighted the discriminatory nature of the order, particularly pointing to the fact that U.S. borders remain open to tourists and citizens arriving by plane or ship, which are both congregate settings with higher risk of disease transmission than land travel.[21] Rather than expelling children, adults, and families into potentially dangerous settings, experts have recommended effective and evidence-based public health measures for processing asylum seekers at the border. These include measures already implemented nation-wide, such as COVID-19 testing, masking, social distancing, and quarantining.[22]


President Biden and the CDC Continue the Title 42 Ban


During its first months in office, the Biden administration took steps to reverse some of the harmful immigration policies of the previous administration, including the “Remain in Mexico” policy.[23] The Title 42 expulsion policy, however, has remained in place, expelling thousands of asylum seekers back across the border to unsafe settings. At the time of this writing, CBP has carried out more than 980,000 expulsions at the border,[24] with immigrant rights groups documenting at least 3,726 new attacks and kidnappings on migrants and asylum seekers who were expelled or stranded in Mexico due to this policy.[25] Those expelled were originally from at least 17 countries. Not only were people sent back to Mexico, but the U.S. government also sent numerous flights with at least 1,200 people back to Haiti, despite pushback from immigrant rights groups and media reports showing dangerous and unstable country conditions there, especially since the assassination of Haiti’s president.[26]


In addition to the harms that asylum seekers face after being expelled to Mexico or to their countries of origin, the expulsions also have other harmful consequences. From January to May 2021, the administration was detaining and flying people to distant parts of the border to expel them far from where they had crossed.[27] The U.S. government faced challenges in housing rising numbers of unaccompanied children, at least 2,100 of whom had already tried to cross with their parents and were expelled under the Title 42 order or had crossed with other relatives who were their primary caregiver, only to be separated from them.[28]


Medical professionals in Tijuana, Mexico have also witnessed that overcrowding in migrant settings there due to the expulsions is causing a rise in concerning medical conditions in newborns and young children, such as dehydration, malnutrition, and infectious diseases.[29] Doctors providing care have stressed the lack of services available for these families and individuals and the alarming potential consequences. As one clinician reported, “Chronic diseases and mental health disorders, left untreated, could become death sentences.”


The administration has agreed to process 250 asylum seekers each day who are deemed vulnerable, as well as 35 families per day as a result of ongoing litigation.[30] Many immigration advocates, however, argue that this is not nearly enough. As of this writing, reports suggest that the administration will move to end the Title 42 order for families at the end of July 2021 – but would continue to ban the entry of single adults.

In the light of the Biden administration’s continued expulsion of all asylum seekers except for unaccompanied minors, in May 2021, Physicians for Human Rights sought to understand the experiences and to document the psychological symptoms of adult asylum seekers currently residing in Mexican border cities who had been expelled due to the Title 42 order.

A father and two of his sons who fled Guatemala together have been expelled twice after trying to reunite with his wife in the United States.

A father who fled Guatemala with his three children and who has been expelled twice after trying to reunite with his wife in the United States. Photo: Lizbeth Chávez for Physicians for Human Rights


Methodology


Data Collection and Analysis


From May 17 to 28, 2021, Physicians for Human Rights (PHR) researchers conducted semi-structured interviews with 28 adults seeking U.S. asylum and with six health care providers in Mexico. All interviewed asylum seekers were 18 years of age or older; were living in Tijuana or Ciudad Juárez, Mexico at the time of the interview; had been expelled due to the Title 42 order; and reported separation from family members due to expulsion. All interviews were conducted in person, in Spanish, and with appropriate COVID-19 precautions. Interviews lasted 30 minutes to one hour. Participation was voluntary, and all participants provided informed verbal consent to participate in the study. Four hundred pesos (equivalent to approximately $20.00 at the time of the interview) were offered to participants as reimbursement for a standard meal and transport. Local shelter directors in Tijuana and Ciudad Juárez referred 27 people for interviews, and an immigration attorney referred one participant.


The semi-structured interview questionnaire covered three main topics: 1) Participant characteristics; 2) Experiences at the border and of family separation due to the Title 42 order; and 3) Current psychological health. PHR researchers used validated Spanish-language screening tools to screen participants for mental health symptoms, including the PCL-5 Civilian scale for post-traumatic stress disorder symptoms, and the Hopkins Symptom Checklist (HSCL25) for anxiety and depression symptoms. The research team collected quantitative and qualitative data during the interviews and stored the data in Box. Researchers analyzed the qualitative data in Dedoose (Version 8.3.45) and the quantitative data in Excel (Version 16.49).


This study was reviewed by the University of Michigan Medical School Institutional Review Board and determined to be exempt from further review. The study also received Institutional Review Board approval from PrevenCasa, a health care organization located in Tijuana, Mexico, and from PHR’s Ethics Review Board.


Researchers conducted 27 of the 28 interviews in person at the shelter where the participants lived and one interview in person in an encampment; the researchers conducted interviews in private rooms when available. Before each interview, the PHR researchers reviewed a consent form with the participant and obtained verbal consent to publish de-identified information in a PHR report. The researchers also provided information and referrals for mental health services as needed.


Limitations


The data in this report represents the experiences of 28 people expelled from the United States under the Title 42 order before the end of May 2021 who are now residing in Tijuana and Ciudad Juárez and may not represent the experiences of others affected by this policy, people expelled to other areas of Mexico, or those expelled after June 1, 2021. The participants were referred by directors of shelters or immigration attorneys rather than through a statistically random sampling method. Interviews were conducted in Spanish only, so the experiences of immigrants who do not speak Spanish or English are not represented. Nevertheless, the consistency of the narratives across locations and the richness and density of the interview details strongly corroborate the relevance and internal validity of the data.


Findings


Asylum Seeker Participant Characteristics


Table 1 describes characteristics of the 28 asylum seekers interviewed. Twenty identified as female and eight as male. Participants ranged in age from 22 to 44 years, with a median age of 31 years. The participants came from four different countries (16 from Honduras, nine from Guatemala, two from El Salvador, and one from Mexico). Participants’ primary languages were Spanish (25 people) and indigenous Mayan languages (three people). All interviews were conducted in Spanish. Six participants described attempting to cross the border more than once within the past year. The majority of participants crossed through Reynosa (20 people); however, various other crossing sites (Ciudad Juárez, Miguel Aleman, Piedras Negras, and more) were also identified.


Of the six health care providers interviewed, two were physicians and one was a nurse who provide direct clinical care at clinics in Tijuana, two were coordinators for a clinic in Tijuana, and one was a psychologist providing mental health care in a clinic in Ciudad Juárez.


Table 1. Asylum Seeker Participant Characteristics


Individual-level Variables Frequency Percent Median

Age 31

Gender

Male 8 29%

Female 20 71%

Country of Origin

Honduras 16 57%

Guatemala 9 32%

El Salvador 2 7%

Mexico 1 4%

Language

Spanish 25 89%

Indigenous 3 11%

Reason for seeking asylum

Gang violence 22 79%

Domestic violence 3 11%

Medical Needs 2 7%

Not identified 2 7%

Attempted number of crossings

1 22 79%

2 5 18%

3+ 1 3%

Site of border crossing

Reynosa 20 57%

Miguel Aleman 4 11%

Ciudad Juárez 4 11%

Other 7 20%


U.S. Officials Expelled People to Unsafe Conditions in Mexico, Blocking Access to Asylum


Almost all the people interviewed (25 people) came to the border to seek asylum in the United States due to gang violence or domestic violence in their home countries (see Table 1). Families reported repeated crossings, often in dangerous conditions – in flimsy rafts, wet and cold, carrying their children, sometimes injured, sometimes with smugglers who abused, robbed, or extorted them – in their desperation to find refuge in the United States. A 31-year-old mother reported carrying her child in her arms for six hours trying to cross. Another mother described crossing the Rio Grande with her two young children aged four and six years and the hopes that motivated their willingness to face that danger. “We put our life at risk thinking that we would not be returned.”


Interviewees reported that U.S. officials rebuffed all their attempts to seek asylum. As one woman recalled, “I asked for asylum, but [the U.S. border agents] did not answer me, and I was taken to the detention station.” Another woman said, “I tried to tell them my story, but they did not listen. They told me, ‘No. There is no asylum.’” A 26-year-old woman said, “I told them that I was seeking asylum, but they told me that there was no asylum because of the pandemic. The agents told me that they are not giving asylum to people from Honduras; they are only giving asylum to Cubans, Colombians, and Venezuelans.” A psychologist in Ciudad Juárez noted the impact of being denied the right to seek asylum, saying, “I would tell the politicians that everyone has the right to ask for asylum. Losing this right directly affects the mental health of these people. These people put themselves at risk to seek asylum, and these risks make them even more vulnerable.”

“No one feels safe here. I have seen a lot of violence. I hear people being kidnapped in the night. Last week two kids were kidnapped. We also found someone who had been murdered the other night. It is very dangerous here.” 32-year-old man from El Salvador

People described being caught in an impossible situation, as they are unsafe in their own country, unsafe in Mexico, and yet cannot seek safety in the United States. As one woman said, “I cannot go back to my country. I cannot live there due to the violence. I cannot live in Mexico due to the violence. Where am I supposed to go?” Another woman described her absolute desperation to cross the border to find safety, “I hope to God that they give me political asylum, because otherwise I will have to throw myself into the desert with my children to cross again.”


Asylum Seekers Were Victims of Kidnappings, Extortion, and Violence in Mexico


When asked if they feel safe in Mexico, 27 people – all but one of the asylum seekers interviewed – said that they did not feel safe. People told PHR researchers that they had been assaulted, kidnapped, extorted, and subjected to physical and sexual violence in Mexico.


Five of the interviewed asylum seekers described being kidnapped after being expelled to Mexico. One mother described being kidnapped by “the Mafia,” who locked her and her children in a room and threatened to keep them captive until they paid a ransom; when it was clear that she had no money to pay them, they forced her to work for them, not allowing her or her children any food. She said she was kidnapped with a group of other migrants who were also mistreated. “There was a girl there that they raped. My daughter has breasts already so I was very afraid that they would do something to her. Every time I left to work, I asked God to watch over my children. I was afraid that they would turn us into slaves. Whenever I saw my son talking to them, I was afraid that the coyotes would recruit my son as a drug smuggler.”


Extortion was commonly reported by interviewees, as criminal elements sought to exploit their vulnerability as migrants in Mexico. Six asylum seekers described being extorted and threatened after they were expelled to Mexico, even if they moved or were expelled to different cities in Mexico. One father stated, “In Juárez, I received a message from an unknown male demanding that I pay $2,000 or he would kill me and my child. I paid all the money due to fear, and now I do not have any money. Now the person is sending me WhatsApp messages demanding money once again; he says that he knows I am in Tijuana, and if I do not pay, he says that he will kill me and my child.”

“There was a girl there that they raped. My daughter has breasts already so I was very afraid that they would do something to her. Every time I left to work, I asked God to watch over my children. I was afraid that they would turn us into slaves.” 32-year-old woman from Guatemala

Interviewees reported that they did not have access to state protection from Mexican authorities. Several people reported that Mexican immigration officials had asked them if they wanted to apply for asylum in Mexico. However, because Mexican authorities had not provided protection from violence, interviewees did not believe that asylum in Mexico was a safe option. In fact, several people reported that Mexican federal agents themselves robbed and extorted migrant amilies after they were expelled from the United States. Said one woman, “The Mexican military stopped me and asked for my ID. After I told them that I didn’t have any documents since I had been migrating, they stole all my money and phone.” Another woman reported a similar experience, where federal Mexican agents detained her for three hours, threatened her, and took her money and phone; heartbreakingly, it was on the stolen phone that she had photographs and other proof of extortion she had endured in her home country, precisely the evidence needed for an asylum claim.

Although some interviewees mentioned that Mexican authorities brought them to shelters, other asylum seekers said that living conditions in the encampments and shelters were unsafe. One person shared, “I do not feel safe in the Chaparral encampment. No one feels safe here. I have seen a lot of violence. I hear people being kidnapped in the night. Last week, two kids were kidnapped. We also found someone who had been murdered the other night. It is very dangerous here. I also feel very sad here, because I do not know anyone. I do not know Tijuana. I am all alone.”

“In Juárez, I received a message from an unknown male demanding that I pay $2,000 or he would kill me and my child. I paid all the money due to fear…. Now the person is sending me WhatsApp messages demanding money once again; he says that he knows I am in Tijuana, and if I do not pay, he says that he will kill me and my child.” 22-year-old man from Honduras

Health care workers corroborated the high levels of violence experienced by migrants they treated in northern Mexico, and the mental health impact of that violence. A physician who works in Tijuana, Mexico reflected on re-traumatization caused by kidnappings, gang rapes, and extortion of families, saying, “The trauma from these immigrants’ own countries is compounded by what they go through here.” A psychologist who works with asylum seekers in Ciudad Juárez stated, “Many women are victims of gender-based violence and sexual violence, and they are just returned without having their case heard. They don’t want to return to Mexico because this is the place where they were raped. These women have a lot of anxiety and fear because of this.”


Despite the toll that living under constant threat of exploitation and danger in Mexico took on individuals and families, the push factors which triggered them to make the journey north made returning to their home countries impossible for many. A doctor in Tijuana described how she provided medical treatment for an 18-year-old girl with a two-year-old son who had been gang raped multiple times in Mexico. She told the doctor that even after being expelled, and despite enduring repeated sexual violence in Mexico, she could not give up on her efforts to get to the United States. “I would do it again, because at least my son will get a chance” to be safe from the threats he faced at home to force him to join a gang.

A 44-year-old Guatemalan father being interviewed about how he was beaten by U.S. agents when he tried to request asylum in the United States.

A 44-year-old Guatemalan father who was beaten by U.S. agents when he tried to request asylum in the United States. His teenage children were knocked to the ground and handcuffed.Photo: Lizbeth Chávez for Physicians for Human Rights


During Expulsion, U.S. Officials Subjected Asylum Seekers to Inhumane Treatment and Poor Public Health Conditions


The U.S. government continues to expel asylum seekers without giving them an opportunity to seek asylum and is exposing them to further violence in Mexico. According to our respondents, U.S. government officials also directly violated the rights of migrants during the expulsion process. All the asylum seekers interviewed described gratuitously cruel and inhumane treatment at the hands of the U.S. government, including physical and verbal abuse by U.S. officials, inhumane detention conditions, active deception and provision of false information about their expulsion and the whereabouts of their family members, and unsafe returns that put people at heightened risk of harm.


Physical and Verbal Abuse by U.S. Border Officials


After surviving harrowing journeys to and across the border, even in U.S. custody families were not safe. Several families reported physical violence and death threats by U.S. officials, including against children.

In one terrifying incident, a mother described Border Patrol agents intentionally capsizing and destroying an inflatable raft that was holding a group of migrants, including small children. Adding to the physical risk was the cruelty of U.S. agents threatening and mocking the frightened parents. The mother who crossed the border near Reynosa, Mexico, recounted,


“All the mothers were terrified that our children would be swept by the current and our children would drown. The agents began to stab the inflatable raft. It was so inhumane the way we were treated by the U.S. agents. They knew about the risks and saw the children on the raft, but regardless they chose to flip the raft and they saw how desperate we became thinking our children were going to drown. They then threatened us, mocked us, and used obscene words.”


Instead of rescuing families who were vulnerable in the river, U.S. border officials threatened their safety.

All of the asylum seekers interviewed described gratuitously cruel and inhumane treatment at the hands of the U.S. government, including physical and verbal abuse by U.S. officials, inhumane detention conditions, active deception about their expulsion and the whereabouts of their family members, and unsafe returns that put people at heightened risk of harm.

In another case, an asylum seeker described an episode in which border officials beat him and his two children when they tried to set foot on U.S. soil in order to claim asylum:


“Six agents ran towards me. One agent shoved me down. Another agent put his knee on my spine, and I could not breathe. Everything was happening very fast, so I don’t remember all of it. Someone took a video and it was shown on the news. I saw that the agent’s knee was on my back for 40 seconds. On the video I saw that one of the agents pointed a weapon at me, I don’t know if it was a gun or a taser. They also knocked my daughter to the ground, and she fell to her knees, and they handcuffed her. They also threw my son to the ground, and then they also handcuffed him; the handcuffs left a mark on his wrist…. They are only children, they are only 13 and 14 years old.”


Two families reported that U.S. officials threatened to shoot them and their children. One woman was told that if she and her children did not comply with the expulsion, the U.S. officials would shoot them. Another mother described that she was putting on her small son’s lifejacket on a raft crossing the Rio Grande into the United States when Border Patrol agents flashed their lights and threatened to shoot anyone who moved.

“The agents flipped the inflatable raft and all of us fell into the water, including many children. All the mothers were terrified that our children … would drown. The agents began to stab the inflatable raft. It was so inhumane the way we were treated …. They saw how desperate we became.… They then threatened us, mocked us, and used obscene words.” 28-year-old woman from Honduras

Four of the interviewees described verbal abuse by U.S. border officials. One woman stated, “[The U.S. officials] would make fun of us, and they told us, ‘You can eat the leftovers our dogs don’t want to eat.’ It is really inside detention where the inhumane [treatment] occurs.” Another woman described being berated by U.S. border officials: “The agents were screaming at us. They said very racist things to us. They yelled at us ‘Shut up!’ and ‘You are not in your house’ when we would cry. They would also scream at us, ‘I do not know why you are coming here!’” U.S. officials mocked the asylum seekers. In one case, U.S. officials told a woman that she would be able to apply for asylum and then left her in Mexico, saying “Good luck, until next time,” referring to repeat expulsions when people cross again.


Inhumane Conditions in U.S. Immigration Detention


After entering the United States, 24 of the 28 interviewees reported that they were detained for more than 24 hours by U.S. officials. Twenty-three people were held in detention centers, and one person was also held in U.S. custody in an outdoor fenced area under a bridge. The interviewees were detained for an average of 2.5 days, with a range of 1-4 days. All the people who were detained described poor conditions in detention centers, in particular in U.S. Customs and Border Protection holding cells which are referred to as “hieleras” (“ice boxes”) due to their very cold temperatures. All described “freezing” temperatures inside the detention centers. The families described inhumane treatment, poor sanitation, inadequate and poor-quality food, and denial of medical care, which caused a number of parents and children to become ill. As one mother who was detained with her young child recounted,


“I was detained and held outdoors under a bridge, where it rained all night. My child got very sick. Agents threw away my child’s medicine and the food that I had with me. The next day, we were taken to a hielera, where I was detained for three days. My daughter got worse, and she became very ill. She couldn’t breathe. She was coughing a lot, and she had a fever. All I was told was to give her water.”


Another interviewee described poor conditions in detention, including cold temperatures, poor sanitation, and inhumane treatment while being detained for four days:


“It was very cold. We suffered a lot. They treated us very poorly. They woke us up early for no reason, they didn’t let us clean ourselves, they gave us terrible food – my children did not eat because they did not like the food. There were no showers. My sister was separated from us in the detention station. They didn’t tell me anything about where she was. I was very afraid for her. But the agents did not tell me anything.”


Nine of the interviewees reported receiving inadequate and non-nutritious food. As one interviewee described his treatment in detention when detained for three days with his two-year-old son,


“We were treated worse than animals. They didn’t feed us. They gave us one juice or one apple for my child. Sometimes, they gave me a sandwich, but it was terrible, and I could not eat it. The conditions are terrible in detention – that is the reason they don’t let reporters in.”


Failure to Provide Medical Care in U.S. Immigration Detention


Asylum seekers also described denial of emergency medical care while in federal custody, including for sick children. Some families reported a complete lack of medical screening for people who were exhibiting symptoms of illness, which is a serious risk factor for transmission of infectious disease. As one man stated, “The conditions were bad [in detention], we were all sick, and we were in a room that was very cold and we got even more sick. We were not seen by a doctor, and we did not receive any medical attention.”

“[The U.S. officials] would make fun of us, and they told us, ‘You can eat the leftovers our dogs don’t want to eat.’ It is really inside detention where the inhumane [treatment] occurs.” 28-year-old woman from Honduras

In some instances, U.S. officials denied requests for any medical care at all, even when the person had a known chronic condition, and after confiscating their prescribed medication. As one mother described,


“We asked for a doctor, and we asked for medicine for my child because his lungs are bad. He has bronchopulmonary dysplasia, but [immigration officials] threw away all of his medicine. I was asking for medicine because the doctors told me that my child had to take medicine for his bad lungs. But the border officials told us that they would not give us more medicine. Later that night my baby was crying, and an agent told me to beat my baby so that he would stop crying.”


In other cases, even when a medical professional came to make an assessment, no treatment was provided. A 23-year-old mother reported that her daughter had lost an alarming amount of weight; a doctor at the detention station told her that unless she had test results for her daughter, he could not help her. Another mother reported that border agents refused to follow the medical orders of a doctor to fulfill a prescription for an acutely ill child:


“The doctor gave the agent a paper with the prescription for the three medicines. The agents then took us back to the station. The agent gave me the prescription paper and said, ‘This is not my problem.’ I could not get the medicines.”


During a pandemic, the U.S. government is detaining migrants in crowded, inhumane, and unsafe conditions for days before expelling them, and is denying children necessary emergency medical care.

“I was asking for medicine because the doctors told me that my child had to take medicine for his bad lungs. But the border officials told us that they would not give us more medicine. Later that night my baby was crying, and an agent told me to beat my baby so that he would stop crying.” 26-year-old woman from Guatemala
A shelter for migrants in Tijuana, Mexico.

A shelter for migrants in Tijuana, Mexico.Photo: Lizbeth Chávez for Physicians for Human Rights


Poor Public Health Conditions in the Face of COVID-19


Although the Title 42 order is characterized by the Biden administration as a public health policy, every aspect of the expulsion process, such as holding people in crowded conditions for days without testing them and then transporting them in crowded vehicles, increases the risk of spreading and being exposed to COVID-19. One woman pointed out that other precautions, such as testing, could easily be taken while admitting asylum seekers, saying, “Using the COVID pandemic feels like an excuse to not allow people to seek asylum, because there are tests that can be done, like COVID tests. Before I left Honduras, I got a COVID test. We always wear masks in the street, we are very careful. But they still separate families.” Another woman also questioned the border closure, when it would be possible to quarantine, saying “I do not understand why the border is closed because of COVID. If we were sick, we could quarantine in the United States. If we do not have symptoms of COVID, why did they return us?” Another woman described being handed over to Mexican federal authorities, who ignored her questions and left her and her family in a shelter where people had COVID-19. A psychologist in Ciudad Juárez noted the political interests underlying the Title 42 order, saying, “The COVID pandemic has served as an excuse to expel all these migrants. People from the USA still come to Mexico. It is due to politics, not due to health.”


Deception by U.S. Border Officials about Expulsion and Family Reunification


Instead of providing clear information to migrants about the expulsion process, U.S. border officials not only refused to provide basic information to those they detained and expelled, they also frequently deceived and actively provided false information to asylum seekers.


Sixteen interviewees reported not receiving information related to their expulsion. Some described asking for information about what was happening to them from border officials, who refused to tell them anything. One interviewee shared, “They did not tell us why we were being expelled or what was happening. We asked questions, but they did not tell me anything. We did not receive any documents or information, they just kicked us out.”

“We were then put on a plane and when I asked where we were being taken, we were told that we were going to be reunited with my family in the U.S. … This was a lie. We were put on a bus and … we were expelled to Tijuana.” 28-year-old woman from Honduras

Other interviewees described begging for information about separated family members when U.S. officials refused to provide any information about their whereabouts. For example, one father described his desperation as he sought information about his family:


“I kept asking [immigration officials], but they did not answer my questions about what was happening or where my wife was. No one told me where my wife or my child were, there was no information…. We were deported by a bus, and we were dropped off on the street and had to cross to Ciudad Juárez at 8:00 at night. I was asking why they sent us back, but they did not give me a reason.”


A mother recounted asking for her son’s whereabouts when she was being expelled:


“We were flown to San Diego, where a bus was waiting to take us to the border. Then we were told ‘You are going to Mexico, we’re not giving you any type of permit.’ I kept asking them where my son was, but they didn’t help me.… I [kept asking] about my kid and I was repeatedly told that they didn’t know where he was and that was something they didn’t care about.”

“I kept asking them where my son was … and I was repeatedly told that they didn’t know where he was and that was something they didn’t care about.” 33-year-old woman from Honduras

Interviewees repeatedly told PHR that the only way that they found out the whereabouts of their separated family members was through social media. One man described how he was still unable to find his wife after many attempts: “I have been unable to message or call my wife. Her phone keeps going to voicemail, and she is not seeing my messages. Because of this, I think she is being detained somewhere.”


Ten interviewees reported being intentionally deceived by immigration officials, particularly during the expulsion process. Common lies were that the U.S. officials were taking them to a shelter in the United States, to apply for asylum in the United States, or that they were being transferred to another detention center in the United States; interviewees only realized after they left the transport vehicle that they had instead been expelled to Mexico, often to a city where they had never been before. For example, one mother stated,


“We were then put on a plane and when I asked where we were being taken, we were told that we were going to be reunited with my family in the U.S., and that we would wait at a shelter in San Diego. This was a lie. We were put on a bus and … we were expelled to Tijuana.”


The deception seemed to be used intentionally, in order to coerce asylum seekers to comply with expulsion. As a 33-year-old woman described, “I was crying, mothers were crying, and fathers were crying. The border officials yelled ‘Why are you all crying? Nothing is happening. We are taking you to another shelter.’ This was a total lie.”


Even more cruelly, U.S. officials deceived people about being reunited with family members, while, in reality, they were separating them. For example, a father described being expelled with his young son to northern Mexico, while U.S. officials were telling him that he was “reuniting” with his wife and other child: “The day I was deported, they told me that my son and I were being sent to another shelter in San Diego to reunite with my wife. But they took us to the border of Ciudad Juárez and left us. We were kidnapped that night in Ciudad Juárez for five days.”

“At 1 a.m. they left us at the bridge in Juárez. I asked them why they would throw us to the streets at night with children, and an agent said, ‘That’s your problem, that is not my problem.’ There was no reason to treat us this way. We are humans too.” 35-year-old man from Honduras

Unsafe Returns Carried out by U.S. Officials


Many asylum seekers described how U.S. officials expelled them under extremely dangerous conditions. For example, seven asylum seekers reported being expelled to border towns in Mexico late at night, even with children, when they would be much less likely to be able to reach a shelter and which exposed them to increased risk of targeting by cartels. One interviewee described his exchange with a U.S. border official while being expelled to Ciudad Juárez at night: “At 1 a.m. they left us at the bridge in Juárez. I asked them why they would throw us to the streets at night with children, and an agent said, ‘That’s your problem, that is not my problem.’ There was no reason to treat us this way. We are humans too.”


Another asylum seeker described being violently threatened by U.S. border officials during her expulsion at night to Ciudad Juárez: “I began to cry and ask them not to expel me. I asked them if I could stay at least for the night in the station because I did not know anyone in Mexico. They told me, ‘We are not here to deal with children and women, we are here to shoot. So, if you do not leave, we will shoot you.’ We were expelled at 10:30 p.m.”


Interviewees also described being sent to unfamiliar locations far from where they crossed the border, in so-called lateral expulsions.[31] Twenty-two asylum seekers described being subjected to lateral expulsions. For example, 10 asylum seekers entered through Reynosa and were expelled to Tijuana (approximately 1,200 miles away); eight asylum seekers entered through Reynosa and were expelled to Ciudad Juárez (approximately 630 miles away). One interviewee described his distress after being expelled to an unfamiliar city: “We do not feel safe right now in Mexico. We do not know the city or the people here. Everything is different. We don’t know the environment.”

A Guatemalan mother being interviewed about how she was held with her two young children for several days in U.S. immigration custody in what she described as dire conditions before being expelled to Mexico.

A Guatemalan mother who was held with her two young children for several days in U.S. immigration custody in what she described as dire conditions before being expelled to Mexico.Photo: Lizbeth Chávez for Physicians for Human Rights


They told me, ‘We are not here to deal with children and women, we are here to shoot. So, if you do not leave, we will shoot you.’ We were expelled at 10:30 p.m.” 32-year-old woman from Guatemala

Asylum-seekers Were Separated from their Family Members


U.S. Border Officials Forcibly Separated Families at the Border


Under the Biden administration, families continue to be separated, as some family members are permitted to enter, while others are expelled. Of those we interviewed, 11 people were forcibly separated from family members by border officials. Of these 11, eight reported being separated from their spouse or biological children. These separations took place without any consideration of the needs or vulnerabilities of family members, or the age of the children. One father asked U.S. border officials to let his son go with his wife when they were separated, because his son was still breastfeeding: “I told them I don’t want him suffering. But they did not take my baby [to his mother] and they expelled us.”


A mother described being separated from her husband and baby and being denied any information about their whereabouts:


“I was caught by border officials, who asked for my documents and identification. My husband and I were each told to each take one child. I took my three-year-old child, and my husband took our baby. We were then sent to detention and we were separated. I spent two days in detention with my child. I kept asking where my family was, but they did not tell me where my husband and baby were. They did not answer me, or they kept telling me that they didn’t know.”


The pain of possibly indefinite separation was heightened by the fear and anxiety people experienced, as the U.S. officials who separated the families also refused to provide any information about their family members’ whereabouts. Separations took place in a haphazard manner, without any kind of process or opportunity to appeal the separation or any way to seek reunification. It is not clear if U.S. officials were even keeping track of which family members they separated or anticipating any responsibility for later putting family members in contact or reunifying them.


Separation of Non-parent Caregivers from Young Family Members


Twenty people were separated from members of their immediate family, such as their spouse or biological children. A further eight people were separated from family members with whom they were traveling who were not their biological children or stepchildren, but for whom they were the primary guardian, such as younger minor siblings or nieces and nephews.[32]


Amongst eight interviewees who were separated from their family, seven adults reported that they were separated from minors (such as nephews, nieces, or siblings) for whom they were the primary caregiver. One woman spoke about how traumatic her younger sister, whom she raised, found their separation, saying, “When she speaks to me, she cries and says that she wants to be with me, because I am like her mother, too.”


Another woman recounted the pain of being separated from her nephew:


“I raised my nephew since he was a young baby, and my nephew calls me ‘mama.’ … He thinks of me as his mother…. Once [the agents] discovered that I was not my nephew’s biological mother, he was separated from the rest of us. I tried to explain that I am like his mother, but they separated him anyway. I was placed in detention for four days with my 14-year-old girl and four-year-old boy. I kept asking where my nephew was, because I did not know where they sent my nephew.… I did not receive any information from the officials about my nephew’s whereabouts or wellbeing. I later found out that my nephew was detained for one month while he was waiting to go to his mother in Houston. My nephew is very sad.… He constantly calls me and asks me, ‘Mama, why can’t we be together?’ And I keep telling him that I do not know why, and I do not know why we cannot be together.”


Families traveling together did not think that the U.S. government would separate them, especially when family members are vulnerable and need support. In one family, a grandmother was separated from her daughter, who has severe epilepsy, and her granddaughter, both of whom were expelled. Without her mother’s support, the woman with epilepsy was unable to care for her daughter.


One man recounted the sadness he experienced after being separated from his partner, who has cancer, and her daughter:


“I came with my family. I thought that if you presented to the border for asylum together, you would not be separated, and that they would process our family together. It is very difficult for me, because I am thinking of them, but I cannot be with them. I am very sad right now, because my family depends on me, but I am not there…. My daughter is also crying all the time and asking for me.”


In some cases, reliance on extended family means that family members do not have correct documentation. One woman came to the border with her daughter, whose birth certificate has the name of the girl’s grandmother, since the woman was 17 when she gave birth. U.S. border agents separated the mother and daughter under a bridge, without asking any questions to determine who the guardian was. “They did not ask me any questions about whether I was her mother,” the woman said. “I did not know anything about my daughter, and I did not see her again.”


These separations were seemingly carried out with no process for determining the best interest of the child, without the involvement of child welfare experts, and without regard for the trauma and increased vulnerability it causes.

“When we were about to cross the river, we saw immigration and got very scared. My son ran faster. I thought we would be able to catch up with him, but we could not. I never saw him again.” 33-year-old woman from Honduras

Other Forms of Family Separation


In addition to separations directly carried out by U.S. officials, interviewees also described other forms of family separation caused by U.S. border enforcement.


Five families were separated while traveling to or traversing the border, mainly due to aggressive enforcement by Border Patrol or targeting by cartels. Three families were separated while fleeing from Border Patrol in the United States. For example, one father stated, “After we crossed the border, an unmarked bus appeared. Everyone was very afraid, and we all began to run. I grabbed my six-year-old child, and my wife grabbed our four-year-old child. While I was running, I became separated from my wife and four-year-old child.” A mother recounted,


“We crossed the river to the other side. When we were about to cross the river, we saw immigration and got very scared. My son ran faster. I thought we would be able to catch up with him, but we could not. I never saw him again.” Two interviewees described being separated due to kidnappings in Mexico. One mother stated, “I was held by the smugglers and told that they wouldn’t let me and my two-year-old daughter go until we paid them more money for the two of us. The rest of my family was allowed to leave.”


Eight interviewees attempted to enter the United States to reunite with family members who were already there, but they were unable to cross the U.S. border. For example, one mother described attempting to reunite with her 12-year-old son, who crossed into the United States with his father in 2019 but was placed in foster care after his father died:


“When Biden was elected President, my son asked me to come to the United States. He was so excited to see me again. He told me that Biden would not separate families. I could not say no to my son, because he was so hopeful and so excited to see me again. So, I decided to try to cross into the United States to be with my son again. I tried to cross the border in Reynosa, but I was caught by the agents.”


Another mother described how her children beg her to cross the desert to join them in the United States. “This [separation] has affected my children a lot. They are desperate – my children tell me ‘Mami, cross the desert so that we can be together.’”


One interview participant described making the difficult decision to send her young sister across the border alone after learning that children were exempted from summary expulsion. The interviewee shared: “I took my sister, who is 15 years old, to the border so that she could cross. I heard from people that the minors who went alone could cross, and so I took her to the border to cross alone. My sister crossed, and she was allowed to enter.” The possibility of sending children over the border alone is a terrifying risk but keeping them in Mexico is also dangerous. Said one mother, “I would consider sending my children across the border alone. They have suffered so much, if I [send them across the border], it may be better because they may suffer less. I wonder what is safer, for them to be here or to go across alone? But I am too afraid to send them alone.”

A Salvadoran man being interviewed about how he was separated from his partner and daughter by U.S. officials.

A Salvadoran man who was separated from his partner and daughter by U.S. officials.Photo: Lizbeth Chávez for Physicians for Human Rights


This 35-year-old mother from Mexico said she was experiencing symptoms of extreme anxiety and fear after she and her children were expelled to Mexico.

Almost all the asylum seekers interviewed by PHR screened positive for major depressive disorder. This 35-year-old mother from Mexico said she was experiencing symptoms of extreme anxiety and fear after she and her children were expelled to Mexico.

Photo: Lizbeth Chávez for Physicians for Human Rights


Family Separation and Expulsions Contributed to Adverse Mental Health Outcomes


Almost All Interviewees Reported Symptoms of Mental Health Conditions


Almost all the asylum seekers we interviewed reported poor mental health outcomes due to expulsion and family separation under the Title 42 order. Of the 28 asylum seekers interviewed, 26 participants were administered validated screening tools for post-traumatic stress disorder (PTSD), depression, and anxiety. Twenty-five participants screened positive for at least one mental health diagnosis; 25 screened positive for at least two mental health conditions; and 23 screened positive for all three mental health conditions (PTSD, depression, and anxiety).


All those interviewed attributed their current symptoms in part to the pain of being separated from their family members. One father noted that, “When you separate a family, it does not just hurt one person. It hurts everyone, it hurts the whole family. It hurts the children too. The only hope in life is family. And if you do not have family, then you do not have hope…. You can only survive.”

“This [separation] has affected my children a lot. They are desperate – my children tell me ‘Mami, cross the desert so that we can be together.’” 32-year-old woman from Guatemala

Interviewees Described Significant Symptoms of Depression


Almost all the interviewed asylum seekers screened positive for major depressive disorder. In fact, 25 of the 26 interviewees who were administered the Hopkins Symptom Checklist (HSCL-25) screened positive for depression. The HSCL-25 score for depression and anxiety ranges from zero to four, with zero representing no symptoms and four representing the maximum score; a score of 1.75 is considered positive for depression and/or anxiety. Of the 25 interviewees who screened positive for depression, the median score was 2.9, with a range of 2.07 to 3.8. Interviewees also independently recounted depressive symptoms throughout the semi-structured interviews.

“When you separate a family, it does not just hurt one person. It hurts everyone, it hurts the whole family. It hurts the children too. The only hope in life is family. And if you do not have family, then you do not have hope … you can only survive.” 31-year-old man from Guatemala

Throughout their interviews, 25 people described a wide array of depressive symptoms, ranging from loss of sleep to suicidal ideation. For example, one mother shared that, “My mental health is bad because of all of this. I am so sad for my son. Sometimes I want to die, but I have to stay strong for my children.”

One mother described her inability to sleep or eat, stating, “My mental health is bad. I am always afraid, and I cannot sleep or eat. I just want to be with my family again. My mental health here will not be good. It cannot be good until I am reunited with my family.”


Many interviewees also described significant guilt. For example, one woman stated,


“I felt guilty that I could not cross and get my son the [medical] care he needs. The psychologist told me you did an ‘act of love for him, you did what was best for him.’ I stay up at night thinking and crying; I think about how my children [at home] are doing, and if I should have left them or not. I wanted to cross to give my children a better life. I feel guilty when I eat, because we have good food, and we eat three times a day here at the shelter; but my children in Guatemala only eat two times a day. When I feel very sad, I eat a lot of food and I cannot stop, but then I feel guilty about eating, remembering my kids do not have enough food and I do.”


Other participants stated that they found it increasingly difficult to concentrate, which can often be a symptom of depression and/or anxiety. For example, one mother shared, “I feel anguish. I clean to stay distracted. I have been forgetting a lot of things recently. I am in a bad mental place; I feel very stressed. I feel very strange, like my mind is slow. I have trouble concentrating.”

“My mental health is bad. I am always afraid, and I cannot sleep or eat. I just want to be with my family again. My mental health … cannot be good until I am reunited with my family.” 29-year-old woman from Honduras

Interviewees Described Anxiety Symptoms


Most asylum-seekers screened positive for an anxiety disorder. Twenty-four of the 26 interviewees who were administered the Hopkins Symptom Checklist (HSCL-25) screened positive for anxiety. As stated above, a score of 1.75 is considered positive for anxiety and/or depression. Of the 24 who screened positive for anxiety, the median score was 3.1, with a range of 1.8 to 4.


During their interviews, these asylum seekers also described having a wide array of anxiety symptoms, ranging from feelings of nervousness and/or irritability to difficulty sleeping and persistent fearfulness.

One mother described the impact that being separated from her child was having on her mental health: “What I experienced was something horrible that is going to affect me for the rest of my life. I have a lot of anxiety, and I am very afraid all the time.”


Another interviewee described anxiety associated with palpitations and chest pain due to being separated from her husband:


“I was always a happy person. I just wanted to be with my husband. I thought that I was going to be with my husband, but this was not so…. I feel that I cannot rest. I feel very anxious. My heart hurts at night. Sometimes I cannot breathe because of the pain in my heart. I have palpitations. I feel like I am dying sometimes, so I get out of bed and stand up. Sometimes it happens in the day, but it happens a lot more at night. I feel different because of what happened.”


Many other asylum seekers described physical symptoms that they attributed to poor mental health and stress. One interview participant shared, “It is very hard to be apart from my children. I feel very bad. I have been sick for four days. I have pain in my stomach…. I also have headaches. I imagine that all of this is because of the stress. It has affected me a lot not to be with my children.” Another asylum seeker commented on the physical effects of her anxiety: “I have terrible headaches, a lot of tension in my body. I’m struggling to sleep, and I have a low appetite and I’ve lost a lot of weight.”


Of note, these interviewees often attributed their symptoms of anxiety to being separated from their loved ones. For example, a father separated from his child shared that “After all of this happened to us, I am very sad. I have lots of anxiety. I also feel like I was deceived because I thought families could cross the border together. I was diagnosed with depression and anxiety two months ago.”


Interviewees Described Experiencing Symptoms of PTSD


Not only did interviewees overwhelmingly screen positive for depression and anxiety, but a majority of those interviewed also screened positive for PTSD. Of the 26 interview participants who were administered the PCL-5, 23 screened positive for a provisional diagnosis of PTSD. A score of 33 (out of the maximum 80) on the PCL-5 is considered the cut-off for a provisional diagnosis of PTSD. The average PLC-5 score of those who screened positive was 52, with a range of 34 to 76.

“What I experienced was something horrible that is going to affect me for the rest of my life. I have a lot of anxiety, and I am very afraid all the time.” 33-year-old woman from Honduras

The PCL is further divided into categories representing the clusters of types of symptoms required for a diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Participants were asked about symptoms secondary to the events directly leading to separation from their family members, which constitutes the “traumatic exposure” cluster (cluster A). Intrusion symptoms (cluster B), avoidance symptoms (cluster C), negative alterations in cognition and mood (cluster D), and alterations in arousal and reactivity (cluster E) are also measured by the PCL-5. Of the 23 people who screened positive for PTSD, all reported symptoms in each cluster.


During the interviews, many asylum seekers described having symptoms of PTSD, ranging from flashbacks to feeling hypervigilant. For example, one asylum seeker shared the impact of being separated from their family: “I do not sleep anymore. I am always hyper-alert. My situation is very difficult.”

This father, who was separated from his wife and older son by U.S. border agents, said his younger son has been traumatized by the separation from his mother.

This father, who was separated from his wife and older son by U.S. border agents, said his younger son has been traumatized by the separation from his mother. Photo: Lizbeth Chávez for Physicians for Human Rights


Interviewees Discussed the Mental Health Impact of Expulsion and Family Separation on Children


The interviewees also discussed the profound impact that family separation has had upon children in their family. A wide array of symptoms was described, including excessive crying, disturbed sleep, loss of developmental milestones (e.g., resumed bed wetting), and weight loss. Eleven interviewees stated that their children were not eating and had lost significant weight due to the stress of family separation. One mother discussed her son’s mental health symptoms after being separated from her by border officials:

“My son told me ‘I don’t want to be here, without you, anymore. I would rather kill myself.’ We had never been separated before. He calls me crying, telling me that he wants me to take his sister to him. My toddler also wakes up at night looking and asking for her brother. She has also lost a lot of weight. Before leaving my country, about two months ago, she weighed 26.5 lbs and right now she weighs 18.5 lbs.”


Similar symptoms were described by another mother who discussed the impact of being separated from her daughter: “My four-year-old daughter also calls me crying, she is not eating, not sleeping. She calls me at 3 a.m. and if I don’t pick up, she leaves me voice notes saying she wants to be with her sister. She also began to wet and poop the bed again, which she wasn’t doing before.”

“My son told me ‘I don’t want to be here, without you, anymore. I would rather kill myself.’ We had never been separated before.” 33-year-old woman from Honduras

Interviewees also described disturbed sleep amongst children who had been separated from family members. One father shared, “They are very nervous at night. At night, they cannot sleep, and they wake up screaming and crying. My daughter has heart palpitations now.” Another father said, “My son is very traumatized; he wakes up multiple times a night screaming and crying for his mother.”


A third father stated, “The children are innocent, but they are suffering. The separation really affects my son. At night, my boy cries every night for his mother. He is traumatized; he wakes up very afraid. Now he does not play with the other children, he used to play with them in Honduras.”


The interviewees also described troubling behavioral changes amongst their children that they attributed to expulsion and family separation. For example, one father noted that his children have been struggling after being separated from their mother:


“[They] are not the same now that they’re away from their mom…. The love of a mother is unique, and the care of a mother is unique, and they are missing that…. They are very different now. They have a worse temperament, and they are fighting more.”


A mother shared, “The separation has affected all of us a lot. My son’s foster parents called me and told me that he is very depressed. He calls me too, and he is very sad. He refuses to leave his room. He sits all day in his dark room, with the lights off. He is also refusing to eat.” Another mother described her children’s temperament after being separated from their father: “My children’s behavior has also changed a lot. [They used to be] very good. But now they do not want to listen as much. They fight now with the other children…. Now that they are not with their father, they do not want to do anything.”

“We were very traumatized because we were treated very poorly, even though we just had a desire to find freedom…. My children are sad, and very stressed out…. They cannot sleep, and they wake up screaming and crying. My daughter has heart palpitations now. They had never seen a weapon before, much less one pointed at their dad.” 44-year-old man from Guatemala

Health Care Providers Described the Significant Mental Health Impacts of Expulsions and Family Separations


Health care providers interviewed by PHR also commented on the profound impact of the Title 42 order expulsions and family separations on asylum seekers’ mental health. A psychologist who works with asylum seekers in Ciudad Juárez, Mexico stated,


“If they are returned and placed at risk for another trauma, this will worsen their already poor mental health. Most migrants who come here come with a lot of trauma and PTSD…. Anxiety and depression are also very common, and they are often intertwined. Sometimes our clients normalize things, such as not sleeping or not eating.”


The psychologist went on to say that the expulsion process – where migrants have no chance to speak about their case and U.S. officials refuse to provide information or actively deceive them about the process – only worsens health outcomes. The mental health impact is especially devastating, as mental health needs are rapidly escalating while mental health services are swiftly dwindling. A physician who provides health care services to asylum seekers in Tijuana commented,


“We do see [their mental health needs] escalate…. There aren’t enough shelters or spaces for them to live or to be, let alone health services…. Unfortunately, if we do not do something to alleviate the horror and the trauma that these people are going through, we will see more and more severe mental health effects.”


Mental Health Resources Are Scarce for Migrants in Northern Mexico


Although significant mental health symptoms were described by 26 interview participants, only five reported receiving health care services for their mental health. Seven interviewees reported not knowing about mental health resources or how to access mental health care. The lack of mental health services in Tijuana and Ciudad Juárez, Mexico was confirmed by health care providers that we interviewed. For example, a clinic coordinator in Tijuana described the gap between mental health care needs and services: “Recently there are more and more people needing help. But services take longer, a week instead of a day. The health care system has collapsed.” A physician in Tijuana lamented the scarcity of mental health resources as a result of U.S. policy changes:


“The numbers are skyrocketing. Deportations didn’t stop, and then we had COVID and then Title 42. It has been very difficult. The most pressing need is mental health services…. Mental health services, though, are not readily available, even for the Mexican population here. It is not easy to get mental health care, especially if you need specialized care or a hospitalization.”


Legal and Policy Framework


Misapplication of Public Health Law


On March 20, 2020, under pressure from the Trump administration, the U.S. Centers for Disease Control and Prevention (CDC) issued an order under a provision of Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act effectively barring asylum seekers at the U.S. border.[33] Under the guise of protecting public health, the Trump administration claimed the move was a necessary response to the COVID-19 pandemic. The order authorized the Department of Homeland Security to turn away and summarily expel nearly all migrants and asylum seekers arriving at the U.S. border.


The 1944 Act gives the CDC director the power to prohibit the introduction into the United States of people from countries in which a communicable disease is present.[34] Yet nowhere does the Act reference or authorize the executive branch to expel people. In an unprecedented interpretation of the Title 42 provision, the Trump-era order effectively closed the U.S. border to nearly all asylum seekers and evaded U.S. immigration law and the procedures and protections mandated by the 1980 Refugee Act and the 1951 U.N. Refugee Convention.[35]


While the U.S. border has remained open to many travelers since the beginning of the pandemic, asylum seekers have been singled out and categorized as a threat to public health.


Expulsions under Title 42 Violate Rights under U.S. Law


In June 2020, civil and human rights groups challenged the expulsion of unaccompanied children under the Title 42 order in federal court, arguing that it was an unprecedented and unlawful invocation of the 1944 Act and citing violations to the Trafficking Victims Protection Reauthorization Act, the Administrative Procedure Act, the Immigration and Nationality Act, and the U.N. Convention Against Torture, of which the United States is a signatory.[36] The groups won a preliminary injunction, and the Biden administration subsequently announced that it would not expel unaccompanied children, as confirmed by an ensuing CDC order.[37]


In February 2021, a number of families, including unaccompanied children, who had been expelled under the Title 42 rule sued the federal government. The complaint argues that the policy exploited a public health crisis to further Trump’s political anti-immigrant agenda, and violates U.S. immigration law, the Public Health Service Act, the Administrative Procedure Act, and the U.S. Constitution.[38]


Under the Immigration and Nationality Act (INA), all people, including noncitizens, have the right to apply for asylum and cannot be removed without either an asylum screening or a full proceeding before an immigration judge.[39] The INA also includes a mandatory prohibition on “refoulement,” meaning that a refugee may not be expelled or returned to a country where their life or freedom will be threatened on account of race, religion, nationality, membership of a particular group, or political opinion.[40]


All people, including noncitizens, have a right under the Fifth Amendment of the U.S. Constitution to equal protection under the law. Yet, a discriminatory purpose was a motivating factor for the Title 42 order and other regulations which required the expulsions. The Title 42 order was arbitrary, capricious, unlawful, designed to curtail asylum rather than protect public health, and implemented without consideration of measures that could protect public health while maintaining mechanisms for humanitarian relief.


In addition, asylum seekers were expelled in violation of their right to due process under the law, without any of the procedures required by law for removing noncitizens from the United States, and without any opportunity to assert claims to relief.


Violation of Rights in U.S. Custody


As described to Physicians for Human Rights (PHR) by asylum seekers and those caring for them, the treatment of asylum seekers at the hands of U.S. Customs and Border Protection (CBP), which includes the U.S. Border Patrol, and conditions in U.S. custody may violate the right to freedom from torture and cruel, inhuman, and degrading treatment.[41] The UN Committee Against Torture has found that denial of medical care can constitute a violation of the prohibition on cruel, inhuman, or degrading treatment.[42] People described conditions that included verbal and physical abuse, denial of emergency medical care, filthy conditions, and poor quality and inadequate food, even for small children over several days. In addition, the abuses violate CBP’s own rules in the National Standards on Transport, Escort, Detention, and Search.[43] These standards govern CBP’s treatment of detained people and require CBP to provide medical care, adequate food, and humane conditions to those in custody.[44]


Obligations under International Law


The U.S. Government Must Ensure the Right to Health during a Pandemic


The United States is a member state of the World Health Organization (WHO) and has ratified the WHO constitution, an international treaty which affirms that “enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” and which defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”[45] The United States is also a signatory to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which codifies the “enjoyment of the highest attainable standard of physical and mental health” as a human right.[46] Although the United States has not ratified the ICESCR, as a signatory it is obligated to refrain from conduct that undermines the “object and purpose” of the treaty.[47] During a pandemic, fulfilling these obligations requires re-prioritizing resources and taking all possible measures to prevent morbidity and mortality, including through regulation of the private sector, in order to ensure equitable access to treatment and mitigation measures, as well as the protection of health care workers.[48] The Office of the United Nations High Commissioner for Human Rights has also advised that immunization against major infectious diseases is a state obligation under the right to health and therefore that access to vaccination is a human right.[49]


One of the goals of the WHO is to “to stimulate and advance work to eradicate epidemic, endemic and other diseases” (Article 2(g)), a task that requires coordination and cooperation across borders, recognizing that “control of disease, especially communicable disease, is a common danger.” The International Health Regulations (IHR) of the WHO are a legally binding instrument of international law, issued under the authority of Article 21 of the WHO constitution.[50] Article 43 of the IHR requires that all measures states take to address the global spread of disease be grounded in scientific principles, public health evidence, and respect for human rights.[51] In particular, “significant interference” at borders must be carefully scrutinized for their health rationale.[52] Measures that the IHR recommends at borders include providing for the “assessment and, if required, quarantine of travelers,” implementing entry and exit controls, and providing technical equipment and trained personnel to create a safe environment that protects health. UN Principles and Guidelines on Human Rights at International Borders note that states should comply with the WHO IHR when imposing any border restrictions related to public health, as well as with human rights and medical ethics standards of voluntary testing, informed consent, and confidentiality.[53]


The UN Committee on the Protection of the Rights of All Migrant Workers and the UN Special Rapporteur on the human rights of migrants issued a Joint Guidance Note on the Impacts of the COVID-19 Pandemic on the Human Rights of Migrants, emphasizing that government emergency response to the COVID-19 pandemic must have a legitimate public health objective and must be necessary and proportionate in respect to that objective, as well as non-discriminatory.[54] Public health measures must furthermore continue to ensure access to international protection for people fleeing persecution and torture, including non-rejection at the border.[55]


UN experts further recommend that states suspend deportations and enforced returns during the pandemic, pointing out that without proper public health precautions, expulsions can increase exposure to the virus in the destination state, transit states, and the state to which the person is returned.[56] Complying with the state obligation to the right to health also requires respect for the right to health of people in other countries, in accordance with the Charter of the United Nations.[57]


The Title 42 order does not reference any public health reason why migrants and asylum seekers would pose a greater risk of spread of the coronavirus than other travelers, and the CDC Division of Migration and Quarantine refused to support the order, due its lack of a public health basis.[58] Rather, the order bases the border closure on the CBP’s preference for holding asylum seekers in prolonged detention under crowded conditions, despite options for release, mandatory testing, screening, or quarantining, which would have real value in mitigating viral spread and transmission.[59] Indeed, dozens of public health experts developed a series of detailed public health recommendations for border processing during the pandemic, including strengthening public health surveillance and testing capacity, implementing personal mitigation measures (masks, hand hygiene, social distancing), improving ventilation, reducing density in facilities and transportation, and expanding quarantine and isolation capacity.[60]


The U.S. Government Must Ensure Due Process and Effective Remedy for Violations in Removal Processes


UN guidelines clarify states’ obligations regarding border governance under existing human rights instruments. The guidelines emphasize core human rights principles, such as the right to non-discrimination, due process, non-refoulement (the right to not be returned to persecution or torture), the best interests of the child, and the state obligation to provide protection from harm.[61] Although states have the right to limit migration at borders, they have a clear obligation to ensure respect for the rights of migrants during the return process.[62]


The UN guidelines advise that border procedures should fully respect due process, including informing travelers both verbally and in writing about the legal basis and specific reason for denial of entry, as well as the opportunity to challenge denial of entry before a court.[63] People who are eventually returned should only be returned to safe places where they can access essential services; returns should not take place at night, and states should proactively protect returning migrants from criminal groups when returned.[64]


Any denial of entry should only take place through an assessment of each individual case. In response to the expulsions taking place during the pandemic, the UN Special Rapporteur on the human rights of migrants stated that “in the absence of an individualized assessment for each migrant concerned and other procedural safeguards, pushbacks are a violation of the prohibition of collective expulsion.”[65] Collective expulsion without due process is prohibited under international human rights law.[66] A joint statement of the UN Committee on the Protection of the Rights of All Migrant Workers and Members of their Families and the UN Special Rapporteur on the human rights of migrants emphasized that enforced returns of migrants must ensure procedural guarantees under human rights law, such as the right to an individualized assessment, the right to understand the reason for expulsion, access to lawyers and translators, and the right to appeal the validity of the return decision within a reasonable time limit.[67]


In contrast with these fundamental standards, the Title 42 expulsion process is shockingly informal and arbitrary, considering that more than 980,000 expulsions have taken place under the Title 42 order over the course of more than a year and that people continue to be expelled,[68] with no written notice of the reason for expulsion and no real possibility to challenge the expulsion decision.[69] In PHR interviews, people reported that they had not been informed about the reason for their expulsion or detention, were denied information about where they were being expelled to and the location of their family members, did not have access to legal counsel, and were not able to access any grievance or appeal process to challenge any of these enforcement measures or to report ill-treatment by U.S. officials. Moreover, agents have failed to fulfill their duty under international human rights law to ensure that any use of force is absolutely necessary, proportionate to a legitimate objective, and employed in a non-discriminatory manner;[70] pointing weapons and tackling an unarmed man and handcuffing children, as occurred in one case documented by PHR, represent excessive and disproportionate use of force against an unarmed family that was trying to reach the United States to find safety.


These findings are not surprising, considering that the Title 42 order does not outline any procedural safeguards and authorizes CBP personnel, who are not trained to assess protection claims, to summarily deny access to existing immigration processes and procedures.[71]


Conclusions


The Biden administration has continued to expel asylum seeking families and adults under a Trump-era order, despite objections from public health experts that there is no scientific evidence to support this policy. Consistent with the documentation of other human rights groups, Physicians for Human Rights’ (PHR) investigation at the U.S.-Mexico border found that people were expelled by the U.S. government to dangerous areas of northern Mexico where they were not safe, and that during the expulsion process, immigrants were verbally and physically abused, lied to by U.S. officials about where they were being expelled to and about the whereabouts of their family members, detained in inhuman conditions, and separated from family members. U.S. border policies directly and indirectly separated families without considering the best interest of the child during the separation process, thereby increasing the trauma and vulnerability of family members. Family support is a critical resilience factor; its removal is especially harmful to children and has been associated with long-term adverse mental health outcomes.[72]


These abuses and illegal expulsions have been justified as necessary to protect public health. Our findings indicate that the Title 42 order, although ostensibly a public health policy, instead systematically puts people’s health in danger. During a pandemic, lateral expulsions and transfers between detention facilities carried out on crowded planes and buses and congregate detention conditions where people were held for days or weeks would predictably result in the spread of the coronavirus. The conditions reported in U.S. custody are abusive, with detainees being given small amounts of inedible food and being held in very cold temperatures without access to showers, while U.S. officials confiscate any medication, food, or other clothing that asylum seekers might have with them. After making a physically and emotionally exhausting journey to the border, asylum seekers face inhumane conditions that pose a serious risk to their health. Even small children are being detained under these punishing circumstances.


Migrants reported that they and their children became sick due to these practices, and PHR researchers also found high levels of psychological trauma and resulting psychological symptoms among the asylum seekers interviewed. The trauma caused by the U.S. government blocking people from applying for asylum and brutally expelling and separating families was exacerbated by the arbitrary and capricious practice of actively deceiving people about expulsion and separation, while denying them access to basic information, such as where they were being transported and what was happening to them. People described an impossible situation, where they were unsafe in their own country, unsafe in Mexico, and yet unable to seek safety at the U.S. border.


Public health experts have already outlined clear recommendations for how the U.S. government can safely process families, children, and adults at the border; these must be implemented urgently. Every day that the Title 42 order continues to expel asylum seekers is another day that the U.S. government is harming people’s health and violating their human rights.


Policy Recommendations


For the Centers for Disease Control and Prevention and the Department of Health and Human Services:

  • Immediately revoke the Title 42 expulsion order and the related Interim Final Rule and work with public health experts to ensure that border COVID-19 screening guidelines are implemented in line with scientific evidence, public health principles, and human rights standards.

For the Department of Homeland Security (DHS):

  • End the misuse of Title 42 public health authority immediately and restore asylum processing in line with U.S. refugee laws and treaties for all asylum seekers, without exceptions, including at U.S. ports of entry;

  • Follow and implement the Public Health Recommendations for Processing Families, Children and Adults Seeking Asylum or Other Protection at the Border published by public health experts,[73] while re-opening the border;

  • Reorient border processing to swiftly and humanely transport people, including children, seeking asylum from Customs and Border Protection (CBP) custody to community-based shelters or reception locations, while permitting access to CBP facilities for attorneys, the United Nations Refugee Agency (UNHCR), non-governmental organizations, and rights monitors in CBP facilities;

  • Provide independent and trained health, humanitarian, interpretation, and child welfare specialists for border processing;

  • Avoid costly, inhumane, and unnecessary immigration detention by using legal authority, including parole, to release people seeking asylum to live with family and community while their cases are pending;

  • Scale up effective, appropriate community-based case management services operated directly by experienced and trusted nonprofit service providers to refer people seeking asylum for legal information presentations, funded counsel, and other support services that assist those seeking asylum in attending immigration court and presenting claims for protection;

  • Provide redress to the families, adults, and children who were harmed by the Title 42 expulsion policy, including through the provision of government-funded, culturally sensitive, and appropriate mental health and physical health services, as well as by devoting government resources to reunify families separated by the U.S. government;

  • Investigate and pursue disciplinary action regarding cases of abusive conduct by DHS personnel;

  • Preserve family unity by adopting a definition of what constitutes a family to include relationships among parents and their adult children, couples who are in common-law marriages without marriage certificates, pregnant women and their partners, siblings of any age, and extended family members, including grandparents, aunts, and uncles;

  • Document all relationships among family members who travel to the U.S. southern border together, in consultation with child welfare professionals;

  • Ensure that parole or release determinations for any members of a family traveling together are extended to all adult members of that family; and

  • Institute a post-return monitoring mechanism which can track and report on violations that take place during apprehension and removal processes.

For the U.S. Congress:

  • Ensure that adequate resources are provided for trained personnel, such as medical and mental health professionals and child welfare experts, to be able to provide asylum seekers and other migrants a humane reception at the border.

For the Government of Mexico:

  • Ensure that people seeking asylum in the United States are able to access ports of entry, and inform the United States that Mexico will no longer accept non-Mexican citizens expelled to Mexico under the Title 42 order.

Acknowledgments


This report was written by PHR staff members Kathryn Hampton, MSt, MA, senior officer, Asylum Program; Michele Heisler, MD, MPA, medical director; and Cynthia Pompa, Asylum Program officer; and Alana Slavin, medical student at the University of Michigan Medical School.


Interviews were conducted by Cynthia Pompa and Alana Slavin. Joanna Naples-Mitchell, JD, PHR U.S. researcher, Chris Reynolds, medical student at the University of Michigan Medical School, and Melissa Flores, MD, provided input to the interview questionnaire. Former PHR Asylum Program associate Elsa Raker and Kathryn Hampton provided logistics support for the research trip, as did Hannah Janeway, MD, from Refugee Health Alliance.


The report benefitted from review by PHR staff, including Ranit Mishori, MD, MHS, senior medical advisor; Karen Naimer, JD, LLM, MA, director of programs; Joanna Naples-Mitchell, JD, U.S. researcher; Michael Payne, senior advocacy officer; and Susannah Sirkin, MEd, director of policy and senior advisor.

The report also benefited from external review by PHR Board Members Susan M. Blaustein, MMA, DMA, and Gail Saltz, MD and by Kennji Kizuka, JD, MPA, associate director, Research and Analysis, Refugee Protection at Human Rights First.


The report was edited and prepared for publication by Claudia Rader, MS, PHR senior communications manager, with assistance from Samantha Peck, PHR executive assistant, and Noora Shuaib, PHR communications intern. Hannah Dunphy, PHR digital communications manager, and Olivia Falcone, PHR communications intern, prepared the digital presentation.


PHR is grateful for the funding support for this study provided by the University of Michigan Medical School. PHR is grateful most of all to the asylum seekers who shared their stories with us, and for the partnership with Derechos Humanos Integrales en Acción, HOPE Border Institute, Immigrant Defenders Law Center, PrevenCasa, and Refugee Health Alliance.


Endnotes


[1] Jason Dearen and Garance Burke, “Pence ordered borders closed after CDC experts refused,” AP News, October 3, 2020, https://apnews.com/article/virus-outbreak-pandemics-public-health-new-york-health-4ef0c6c5263815a26f8aa17f6ea490ae.


[2] This figure is from March 2020 until June 2021, taking data from the following sources: U.S. Customs and Border Protection, “FY 2020 Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions,” November 20, 2020, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics-fy2020; U.S. Customs and Border Protection, Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions, July 16, 2021, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics.


[3] “July 2021 Letter to HHS Secretary Becerra and CDC Director Walensky on the Title 42 Order,” July 1, 2021, https://www.publichealth.columbia.edu/research/program-forced-migration-and-health/july-2021-letter-hhs-secretary-becerra-and-cdc-director-walensky-title-42-order.


[4] “Public Health Recommendations for Processing Families, Children and Adults Seeking Asylum or Other Protection at the Border,” December 2021, https://www.publichealth.columbia.edu/research/program-forced-migration-and-health/public-health-recommendations-processing-families-children-and-adults-seeking-asylum-or-other.


[5] Jason Dearen and Garance Burke, “Pence ordered borders closed.”


[6] This figure is from March 2020 until June 2021, taking data from the following sources: U.S. Customs and Border Protection, “FY 2020 Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions,” November 20, 2020, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics-fy2020; U.S. Customs and Border Protection, Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions, July 16, 2021, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics.


[7] Bureau of Transportation Statistics, “Border Crossing/Entry Data,” July 8, 2021, https://www.bts.gov/browse-statistical-products-and-data/border-crossing-data/border-crossingentry-data.


[8] “Public Health Recommendations for Processing Families, Children and Adults,” December 2021; Joanna Naples-Mitchell, “There is No Public Health Rationale for a Categorical Ban on Asylum Seekers,” Just Security, April 17, 2020, https://www.justsecurity.org/69747/there-is-no-public-health-rationale-for-a-categorical-ban-on-asylum-seekers/.


[9] Ella Nilsen, “Former Vice President Joe Biden: Trump’s family separation policy is ‘abhorrent,’” Vox, June 20, 2018, https://www.vox.com/2018/6/20/17484414/joe-biden-trump-family-separation-immigration.


[10] 42 U.S. Code § 265.


[11] U.S. Centers for Disease Control and Prevention, “Order Suspending Introduction of Certain Persons from Countries Where a Communicable Disease Exists,” Oct. 13, 2020, https://www.cdc.gov/coronavirus/2019-ncov/order-suspending-introduction-certain-persons.html.


[12] Caitlin Dickerson and Michael D. Shear, “Before Covid-19, Trump Aide Sought to Use Disease to Close Borders,” The New York Times, May 3, 2020, https://www.nytimes.com/2020/05/03/us/coronavirus-immigration-stephen-miller-public-health.html.


[13] Camilo Montoya-Galvez, “U.S. extends stringent border restrictions indefinitely, citing ongoing coronavirus threat,” CBS News, https://www.cbsnews.com/news/us-extends-stringent-border-asylum-restrictions-indefinitely-citing-ongoing-coronavirus-threat/.


[14] American Civil Liberties Union, “Groups File Challenge to Trump Administration’s Illegal Border Expulsions,” June 10, 2020, https://www.aclu.org/press-releases/groups-file-challenge-trump-administrations-illegal-border-expulsions.


[15] Hamed Aleaziz, “Biden Is Dropping Trump’s Policy Of Immediately Expelling Unaccompanied Immigrant Children At The Border,” Buzzfeed News, February 2, 2021, https://www.buzzfeednews.com/article/hamedaleaziz/biden-unaccompanied-immigrant-children-border.


[16] John Burnett, “Judge Says Coronavirus Can’t Be Used As Reason To Quickly Deport Unaccompanied Minors,” NPR, November 18, 2020, https://www.npr.org/2020/11/18/936312918/judge-says-coronavirus-cant-be-used-as-reason-to-deport-unaccompanied-minors.


[17] U.S. Department of Health and Human Services Centers for Disease Control and Prevention, “Public Health Determination Regarding an Exception for Unaccompanied Noncitizen Children from the Order Suspending the Right to Introduce Certain Persons from Countries Where a Quarantinable Communicable Disease Exists,” https://www.cdc.gov/coronavirus/2019-ncov/more/pdf/NoticeUnaccompaniedChildren.pdf.


[18] Hamed Aleaziz, “Biden Is Dropping Trump’s Policy Of Immediately Expelling Unaccompanied Immigrant Children.”


[19] “Public Health Experts Urge U.S. Officials to Withdraw Order Enabling Mass Expulsion of Asylum Seekers,” May 18, 2020, https://www.publichealth.columbia.edu/public-health-now/news/public-health-experts-urge-us-officials-withdraw-order-enabling-mass-expulsion-asylum-seekers.


[20] “July 2021 Letter to HHS Secretary Becerra and CDC Director Walensky on the Title 42 Order.”


[21] Lucas Guttentag, “Coronavirus Border Expulsions: CDC’s Assault on Asylum Seekers and Unaccompanied Minors,” Just Security, April 13, 2020, https://www.justsecurity.org/69640/coronavirus-border-expulsions-cdcs-assault-on-asylum-seekers-and-unaccompanied-minors/.


[22] “Public Health Recommendations for Processing Families, Children and Adults,” December 2021.


[23] U.S. Department of Homeland Security, “Termination of the Migrant Protection Protocols Program,” June 1, 2021, https://www.dhs.gov/sites/default/files/publications/21_0601_termination_of_mpp_program.pdf.


[24] This figure is from March 2020 until June 2021, taking data from the following sources: U.S. Customs and Border Protection, “FY 2020 Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions,” November 20, 2020, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics-fy2020; U.S. Customs and Border Protection, Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions, July 16, 2021, https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics/title-8-and-title-42-statistics.


[25] “Disorderly and Inhumane: Biden Administration Continues to Expel Asylum Seekers to Danger While U.S. Border Communities Stand Ready to Welcome,” Human Rights First and HOPE Border Institute, 2021, https://www.humanrightsfirst.org/sites/default/files/DisorderlyandInhumane.pdf.


[26] Kristina Cooke, Mica Rosenberg, “Where is my aunt? Kids separated from relatives at the border strain U.S. shelters,” Reuters, March 30, 2021, https://www.reuters.com/article/us-usa-immigration-separations/where-is-my-aunt-kids-separated-from-relatives-at-the-border-strain-u-s-shelters-idUSKBN2BM149; Nicole Philips and Tom Ricker, “The Invisible Wall: Title 42 and its Impact on Haitian Migrants,” Haitian Bridge Alliance, the Quixote Center and the UndocuBlack Network, March 2021, https://www.quixote.org/wp-content/uploads/2021/03/The-Invisible-Wall.pdf.


[27] Molly O’Toole, “U.S. border closure cracks under pressure from lawsuits, advocates and the easing pandemic,” LA Times, May 17, 2021, https://www.latimes.com/politics/story/2021-05-17/cracks-open-in-bidens-border-closure-under-pressure-from-lawsuit-advocates-and-easing-pandemic.


[28] Nicole Sganga and Camilo Montoya-Galvez, “Over 2,100 children crossed border alone after being expelled with families to Mexico,” CBS News, May 7, 2021 https://www.cbsnews.com/news/migrant-children-left-families-asylum-border/; Kristina Cooke, Mica Rosenberg, “Where is my aunt?”


[29] Psyche Calderon, Hannah Janeway, and Ronica Mukerjee, “A Trump-era Pandemic Policy is Undermining Public Health at the Border. Biden Must End It.” LA Times, June 23, 2021, https://www.latimes.com/opinion/story/2021-05-27/title-42-border-immigration.