Introduction

The world is in the midst of a crisis of displacement; last year 44,000 people worldwide were forcibly displaced from their homes on a daily basis and, by the end of 2017, the total number of displaced individuals was almost 68.5 million. [1] Refugees are defined as persons who are “unable or unwilling to return to their country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion.” [2] Refugees receive this status prior to entering the US and, by contrast, asylum seekers apply for this designation after arrival in the US, no matter the means by which they entered the country. Seeking asylum is both completely legal in the US and also accepted internationally as one of the fundamental rights owed to all human beings irrespective of religion, country of origin, race, gender, or any other quality. [3]

With these realities as a backdrop, the current presidential administration has been engaged in a war against immigrants and asylum seekers. Trump has famously and repeatedly promised to build a wall on the southern border of the US and has vowed to sharply reduce legal immigration. He has sought to prevent immigrants from requesting asylum and to prevent the children of immigrants who are born in the US from becoming citizens. Many children have been separated from their families at the border, and in some instances future reunification of families might be impossible. [4] Some of these children who are separated from their families have been forcibly medicated with powerful psychiatric drugs. [5] Additionally, against decades of legal precedent, last year then Attorney General Jeff Sessions ruled that fleeing domestic or gang violence would no longer constitute reasons to qualify someone to receive asylum here. [6] 

In defending these and similar actions, Trump has stated that, “American families deserve an immigration system that puts their needs first and that puts America first.” [7] Inherent in this statement is the notion that immigrants pose a threat to the safety and economic security of American citizens. Additionally, there is often an underlying assumption that conditions in their home countries really aren’t so bad and that sending them home is innocuous for these individuals. 

But are these feelings and assumptions correct? In what follows, we undertake to answer these questions in two ways. First, we will examine the characteristics of individuals seen in one faculty-led asylum clinic within a community-based, academic psychiatry department in the greater Boston area who are seeking legal status here in the US.  That analysis will provide some preliminary data about a subset of asylum seekers. We will then also examine what is known broadly about asylum seekers and then argue that for humanitarian reasons as well as utilitarian ones, the US has an obligation to ensure asylum seekers are treated fairly and legally.

Methods and Results: 

Data were extracted from the written reports of evaluations written by one of the authors (JWB) from asylum seekers who had a psychiatric evaluation through the authors’ hospital’s asylum clinic between 2009 and 2017. A variety of demographic were abstracted from evaluation review, including comprehensive data regarding individuals’ motivations for fleeing their country of origin and fears for persecution and/or death if individuals were forced to return. These data were tabulated and analyzed using Microsoft Excel ® software. Data were presented as mean ± standard deviation and as percentages. The study was approved by the Cambridge Health Alliance Institutional Review Board.

The number of male and female asylum seekers was approximately equal. (See Table 1.) The ages of asylum seekers ranged from the youngest, who was 8 years of age, to the oldest, who was 54 years of age, and the average of the entire cohort was 30 ± 10 years of age.  The median amount of time that individuals had been in the US prior to their evaluations was 3 years. Nine individuals had resided in the US for a decade or longer before they received their evaluations, including one extreme outlier who had lived in the US for 30 years prior to his evaluation. The majority of the individuals who were evaluated had limited formal education, with an average of 9 ± 4 years. Most individuals hailed from Latin America, including 13 (22 percent) from El Salvador, 9 (14 percent) from Guatemala, and 5 (8 percent) from Haiti. Seventeen percent were from Sub-Saharan African Countries, 4 percent were from the Middle East-North Africa region and 6 percent from Asia. 

Two-thirds of individuals had family who remained behind in their home country. These individuals described many reasons for seeking asylum here in the US, including escaping persecution for political activities, sexual orientation, religious belief, or because they feared intrafamily or gang violence. All told, 34 percent of those evaluated reported being victims of intrafamily violence, including intimate partner violence.

Most of the individuals fleeing gang violence were from Central America, with El Salvador and Guatemala being the countries most frequently fled. Many of these individuals had family members who were killed by gangs and were repeatedly threatened with death themselves. Twenty-five percent of individuals (many who hailed from sub-Saharan African countries) were fleeing violence because of their political activism. Thirteen percent were fleeing their countries because of religious persecution. 

Seven individuals (11 percent) had committed crimes while here in the US. None of these individuals were recent emigres and most of them had lived in the US from early in their lives and had been arrested for drug related charges. Only one was arrested for a violent crime, and that occurred when the individual was in the middle of a psychotic episode and assaulted a hospital worker. No individual had plotted, attempted, or committed murder.

All individuals were deemed to be credible and none of them were thought to be malingering. (See Table 2.) Eighty-eight percent of individuals met diagnostic criteria for PTSD, while 34 percent met criteria for major depressive disorder. Approximately half of the clients in this cohort reported previously receiving some form of psychiatric care, although many of these individuals reported only receiving emergency department care and were not meaningfully engaged in the mental health system. 

Ninety percent of participants believed they might, or would be, killed if they were forced to return to their countries of origin, and 95 percent of participants believed that they would face violence if they were forced to return. One-hundred percent stated they believed their symptoms of mental distress would increase if they had to return to their country of origin. 

Discussion:

Asylum seekers in our sample had significant rates of both major depression and PTSD. These data are in line with national estimates of these disorders among asylum seekers. [8], [9], [10] Additionally, every individual’s story was deemed credible; almost every one would experience a worsening of their symptoms or would be killed if they were returned to their countries of origin.

Some of the individuals in our study had committed crimes, but given that approximately 1 in 3 Americans will have been arrested by age 23, [11] our cohort had far lower rates of arrests than that of Americans generally. Our data are in line with national data that show immigrants are much less likely than native born Americans to commit crimes or be incarcerated. [12]

Given that data show asylum seekers have significant psychological trauma, and also don’t pose risks to the US, the US ought to ease the path to asylum for both utilitarian and deontological reasons. Some would argue otherwise, claiming that asylum seekers are really coming to the US for economic and lifestyle reasons and, as a result, there is no compelling moral argument to promote immigration. They might also argue that the US first and foremost ought to concern itself with the well-being of its own citizens and not residents of other countries. In this same vein, they might further argue that foreigners utilize resources here in the US that should be reserved for US citizens and legal residents.

Even though these sentiments are widely expressed across the US, these arguments are wrong. Overwhelmingly, asylum seekers face death if they go back to their countries of origin. We have seen many individuals who fled when family members were killed after refusing gang demands, lesbian women who fled after being repeatedly raped because of their sexual orientation, and members of opposition political parties who fled after being threatened with death themselves and watching their compatriots be murdered. In each of these instances, the government was either indifferent to their fate or else actively encouraged the behaviors. We strongly argue that these individuals are not fleeing for economic or “lifestyle” reasons.

Deporting individuals back to their countries of origin under these circumstances seems cruel, to put it mildly. The 8th Amendment of the US Constitution prohibits cruel and unusual punishment and the United Nations Convention against Torture forbids countries from transporting individuals to any country where there is reason to believe they will be tortured. The individuals we have seen would experience a worsening of their psychiatric symptoms and face either harm or death upon arrival in their home countries. Deporting these individuals would appear to be not only unethical, but illegal as well. 

Some might argue that immigrants in general, and asylum seekers in particular, take away jobs from Americans or sap resources here in the US.  In fact, immigrants do not cause wages to be lower in the US, or employment rates to decrease. [13] The reality is that immigrants—including undocumented ones—are vital for a number of US industries, including the farming industry, the construction industry, the restaurant industry, cleaning services as well as many others. [14]

With respect to crime and safety, immigrants are also far less likely than native born Americans to commit crimes—including murder—or be incarcerated. [15] When it comes to health care, expenditures for immigrants are far lower than for U.S. born individuals. Health care expenditures for undocumented immigrants are lower still. Immigrants actually subsidize the American private insurance market, being generally younger and healthier than native born Americans. [16] Immigrants also subsidize Medicare in that they contribute far more into Medicare than they ever receive in terms of services. [17]

Given these realities, there are multiple utilitarian arguments that can be made to support assisting asylum seekers’ efforts to gain legal status in the US. In addition to appeals to morality and conscience given the horrors many asylum seekers are fleeing, the strong utilitarian argument demonstrates that immigrants make a net positive contribution to the US. Indeed, a report by the Department of Health and Human Services that was suppressed by the Trump administration found that “refugees brought in $63 billion more in government revenues over the past decade than they cost.” [18] For all of these reasons, we believe that health care professionals everywhere ought to call for humane approaches to those seeking asylum.  

While many on the right have demonized asylum seekers and perpetrated lies about them, those who care about health and about truth, including health care workers, ethicists and others, have a responsibility to promote beneficence and minimize harm whenever possible. Supporting the rights of asylum seekers is an obvious way to promote these ideals.  In this current political climate, we believe that taking a lead in advocating for the rights of asylum seekers and teaching others about the pain and suffering of asylum seekers across the country is more important than ever.  

Table 1: Demographics of Asylum Seekers (n =64)

Table 2: Asylum Evaluation Outcomes

Compliance with Ethical Standards/Ethical Considerations: The research in this paper was approved by the Cambridge Health Alliance IRB 

Corresponding Author:

J. Wesley Boyd, MD, PhD
1493 Cambridge Street
Cambridge, MA 02139
jwboyd@cha.harvard.edu

Conflict of interest: None of the authors has any financial conflicts or disclosures related to this paper. 

References:

[1] UNHCR. Global Trends Forced Displacement in 2017. Geneva, Switzerland: United Nations High Commissioner for Refugees, 2017. http://www.unhcr.org/globaltrends2017/

[2] United Nations. "Convention Relating to the Status of Refugees." United Nations, Treaty Series, vol 189 in accordance with article 43 (Geneva, Switzerland: United Nations, 1951). https://treaties.un.org/pages/ViewDetailsII.aspx?src=TREATY&mtdsg_no=V-2&chapter=5&Temp=mtdsg2&clang=_en

[3] Draft Committee. Universal Declaration of Human Rights. Paris, France: United Nations, 1948. http://www.un.org/en/universal-declaration-human-rights/.

[4] Sieff, Kevin. "The chaotic effort to reunite immigrant parents with their separated kids." The Washington Post (Washington, D.C.) June 21, 2018.
https://www.washingtonpost.com/world/the_americas/the-chaotic-effort-to-reunite-immigrant-parents-with-their-separated-kids/2018/06/21/325cceb2-7563-11e8-bda1-18e53a448a14_story.html?utm_term=.79d2a054b9fc.

[5] Reuters Staff. "U.S. centers force migrant children to take drugs: lawsuit." Reuters (London, U.K.) June 20, 2018. https://www.reuters.com/article/us-usa-immigration-medication/u-s-centers-force-migrant-children-to-take-drugs-lawsuit-idUSKBN1JH076.

[6] Benner, Katie and Caitlin Dickerson. "Sessions Says Domestic and Gang Violence Are Not Grounds for Asylum." New York Times (New York, NY) June 11, 2018. https://www.nytimes.com/2018/06/11/us/politics/sessions-domestic-violence-asylum.html.

[7] Simendinger, Alexis and James Arkin. "Trump, Senators Push Plan to Cut Legal Immigration." RealClearPolitics (Washington, D.C.) August 2, 2017.  https://www.realclearpolitics.com/articles/2017/08/02/trump_backs_senators_bill_to_curb_legal_immigration_134655.html.

[8] Richter, Kneginja., Lukas Peter, Hartmut Lehfeld, Harald Zäske, Salina Brar-Reissinger, and Günter Niklewski. "Prevalence of psychiatric diagnoses in asylum seekers with follow-up." BMC psychiatry 18, no. 1 (2018): 206. https://doi.org/10.1186/s12888-018-1783-y.

[9] Hameed, Sameena, Asad Sadiq, and Amad U. Din. "The increased vulnerability of refugee population to mental health disorders." Kansas Journal of Medicine 11, no. 1 (2018): 20. https://doi.org/10.17161/kjm.v11i1.8680.

[10] American Psychiatric Association. Mental Health Facts on Refugees, Asylum-seekers, & Survivors of Forced Displacement. Virginia: American Psychiatric Association. file:///Users/wesboyd/Downloads/Mental-Health-Facts-for-Refugees.pdf.

[11] Friedman, Matthew. "Just Facts: As Many Americans Have Criminal Records As College Diplomas." Brennan Center for Justice (New York, NY) November 17, 2015. https://www.brennancenter.org/blog/just-facts-many-americans-have-criminal-records-college-diplomas. 

[12] Riley, Jason L. "The Mythical Connection Between Immigrants and Crime." The Wall Street Journal (New York, NY) July 14, 2015. https://www.wsj.com/articles/the-mythical-connection-between-immigrants-and-crime-1436916798.

[13] Preston, Julia. "Immigrants Aren’t Taking Americans’ Jobs, New Study Finds" The New York Times (New York, NY) September 21, 2016. https://www.nytimes.com/2016/09/22/us/immigrants-arent-taking-americans-jobs-new-study-finds.html. 

[14] Dudley, Mary Jo. "These US Industries can’t work without illegal immigrants." CBS News (New York, NY) January 10, 2019. https://www.cbsnews.com/news/illegal-immigrants-us-jobs-economy-farm-workers-taxes/.

[15] Riley, Jason L. "The Mythical Connection Between Immigrants and Crime." The Wall Street Journal (New York, NY) July 14, 2015. https://www.wsj.com/articles/the-mythical-connection-between-immigrants-and-crime-1436916798. 

[16] Rodriguez, Carmen Heredia. "Immigrants pay more into the healthcare system than they get out of it, study shows." Los Angeles Times (Los Angeles, California) October 2, 2018. https://www.latimes.com/business/la-fi-immigrant-healthcare-20181002-story.html.

[17] Zallman, Leah, Steffie Woolhandler, David Himmelstein, David Bor, and Danny McCormick. "Immigrants contributed an estimated $115.2 billion more to the Medicare Trust Fund than they took out in 2002–09." Health Affairs 32, no. 6 (2013): 1153-1160. https://doi.org/10.1377/hlthaff.2012.1223.

[18] Davis, Julia Hirschfeld and Somini Sengupta. "Trump Administration Rejects Study Showing Positive Impact of Refugees." The New York Times (New York, NY) September 18, 2017. https://www.nytimes.com/2017/09/18/us/politics/refugees-revenue-cost-report-trump.html.