Public Health Challenges and Barriers to Health Care Access for Asylum Seekers at the U.S.-Mexico Border in Matamoros, Mexico

Abstract

The Migrant Protection Protocols (MPP) and border closure to asylum seekers during the COVID-19 pandemic created a humanitarian crisis at the U.S.-Mexico border. This paper outlines the public health challenges and health care access barriers for asylum seekers living in a tent encampment in Matamoros, Mexico resulting from these policies. Thirty participants, including asylum seekers (n=20) and health care professionals (n=10) in the Matamoros asylum camp, were interviewed. Public health challenges included environmental exposures and inadequate infrastructure; poor sanitation and disease control; and limited safety, nutrition, education, and employment. Health care access barriers included lack of continuity of care and emergency services, resource insufficiencies, and interpersonal barriers. Policy responses to address these challenges include outlawing MPP and other immigration policies that infringe on human rights, collaborating with international partners, and implementing more creative and community-based approaches to asylum processing.

Since the enactment of the 1965 Immigration and Nationality Act, the United States (U.S.) has granted asylum to vulnerable people fleeing persecution.¹ An asylum seeker is defined by the United Nations High Commissioner for Refugees (UNHCR) as a person seeking international protection on the grounds of persecution in their home country relating to their race, religion, nationality, political belief, or membership in a particular social group. This population is distinct from refugees or other migrants, as their requests for protection by the home country are not yet finalized, and asylum seekers have the right to wait within the host country until their claims are processed. Nearly all asylum seekers who successfully receive asylum have experienced physical or psychological violence or face an imminent risk to their lives if they return to their home country.²

In 2019, 46,508 people, approximately 15% of applicants, were granted asylum to the U.S.³ Though increasing numbers of Latin Americans have sought asylum, recent policies made doing so more difficult. The Migrant Protection Protocols (MPP), implemented July 2019, allowed border authorities to deport or deny U.S. entry to asylum seekers for the duration of their immigration proceedings, a process that can last years.⁴ Enacted mainly at ports of entry along the Southern Border, MPP specifically affected Spanish-speaking asylum seekers fleeing violence from Mexico, Central America, and South America.⁵ These changes to longstanding U.S. asylum policies created a public health catastrophe at the U.S.-Mexico border, resulting in preventable morbidity for asylum seekers.⁶

Due to MPP, asylum seekers established tent encampments along the U.S.-Mexico border while waiting for their asylum claims to be adjudicated; in the encampments they became susceptible to gang violence, kidnapping, and disease.⁷ In one encampment in Matamoros, Mexico, approximately 2,500 residents, including 500 children, lived in precarious conditions from August 2019 to March 2021, with minimal access to health care and relying on nongovernmental organizations (NGOs) to provide basic services.⁸ The medical NGO working in Matamoros reported significant malnutrition, respiratory illnesses, and gastrointestinal diseases among this population.⁹ The relationship between inhumane conditions and health is clear, particularly among migrant populations.¹⁰ Research has demonstrated how material and experiential disparities can increase morbidity and mortality, and that experiencing repeated stressors and trauma can have immediate and long-term negative effects on wellbeing.¹¹ A lack of access to the social determinants of good health—nutrition, education, employment, safety, and housing, among others—has a strong association to worse health status,¹² particularly among vulnerable groups such as asylum seekers.

Challenges have been exacerbated by the novel coronavirus SARS-CoV2 (COVID-19), with organizations facing difficulties implementing disease reduction policies.^8,12 In March 2020, citing risks of COVID-19, the U.S. closed its border to asylum seekers and indefinitely suspended MPP hearings, stranding 20,000 individuals in Mexico.¹³ Research has shown that health care barriers emerge when countries close their borders to migrants. Studies in Cox Bazar, Sub-Saharan Africa, and Greece demonstrate worse health outcomes when such policies are implemented.^14–15

MPP created significant health care challenges for asylum seekers, which could have lasting physical and psychological consequences. Understanding the effects of MPP on asylum seekers has significant implications for designing future immigration policies and interventions to care for these people as they enter the U.S. The aim of this study is to describe the perspectives of asylum seekers and the health care providers working with them in Matamoros, Mexico to identify public health challenges and health care access barriers facing this population and policy recommendations to ameliorate these challenges.

Methods

Design

A semi-structured interview was adapted from qualitative studies on health care access.^8,16 Questions were validated with health care professionals (n=4) and asylum seekers (n=2), through a process of content validity involving administering the interview and receiving feedback. These individuals were English and Spanishspeaking volunteers affiliated to the local NGOs, with experiencing working in the Matamoros camp and who did not participate in the study. The validation process allowed the researchers to optimize timing, purge superfluous items, and confirm the overarching research objective of identifying public health challenges and health care access barriers facing asylum seekers in the Matamoros camp, through consultation with content experts. The study was considered exempt by The Institutional Review Board at University of Michigan Medical School.

Data collection

In August 2020, 45-minute interviews were conducted with asylum seekers and health care professionals in Matamoros, Mexico. Participants were recruited through snowball sampling with the help of local NGOs, beginning with randomly selected resident volunteers, which was necessary considering the lack of registry from which to sample as well as the need for introductions through trusted sources. All interviews were completed by one interviewer with qualitative research training, who was involved in study design and not affiliated with either local NGOs or government. Collecting data through one, independent researcher helped to assure objectivity and create consistency when clarifying prompts were needed. Consent was obtained by speech before each interview, which were conducted one-on-one in a private location. All interviews were anonymous, audio-recorded, and conducted in Spanish or English according to participant preference. Since more than 95% of the population was Spanish-speaking or English-speaking, offering participants both languages allowed for greater sample inclusion. Data were immediately uploaded to a secure DropBox, a file-hosting service with cloud storage and device synchronization, which is only accessible through encrypted devices.

Analysis

Participants were assigned a code to further guarantee anonymity, and interviews were transcribed verbatim. Codebook development was conducted with a team-based approach, involving validation using repetitively increasing inter-coder agreement (percent agreement=0.94).¹⁷ Transcripts were coded in NVivo12, with frequencies calculated as total participants mentioning that theme.¹⁸ Asylum-seeker and health care professional participants were analyzed together, in view of the shared data collection tool and similarity of responses between each group. Health care access barriers were defined as obstacles that prevented participants from receiving appropriate health care throughout the care process, and any theme with two or more respondents was reported. Themes were categorized into intermediate, immediate, and long-term categories. Quotations reflecting major themes were selected to include a range of participants and translated into English. To ensure data reliability, the following designs were implemented: i) source triangulation with asylum seekers and health care professionals, ii) codebook development among multiple researchers, iii) member checking with aid organizations to ensure data accuracy. Member checking was undertaken by reviewing final themes with staff from local NGOs to confirm accuracy of results and consistency beyond the study collection period.

Results

Demographics

Thirty interviews were conducted among asylum seekers (n=20) and health care professionals (n=10). Table 1 displays demographics of asylum-seeker participants. Asylum seekers lived in the camp ranging from three months to one year, with an average of nine months. Sixty-five percent were unemployed, while 10% were informally employed as street vendors and 25% were formally employed. Though 75% applied for asylum, none received a response at the time of interview. Ninety percent were unable to return home, citing COVID-19 border closures and safety fears in their countries. Participants fled their country for many reasons, including threats, murder of family, and experiencing physical or sexual violence. Six humanitarian organizations worked in the camp, with Global Response Management (GRM), Médicos Sin Fronteras (Doctors Without Borders), and Resource Center Matamoros providing physical health care, mental health services, and sanitation infrastructure, respectively. Figure 1 describes these organizations, which worked together to form a collaborative called "Dignity Village" to provide services to asylum seekers. Among 10 health care professional participants, seven provided medical care and three worked in health services delivery, coordinating logistical operations including supply management and NGO support. Table 2 presents demographics of health care professionals, including four participants contracted by GRM who also sought asylum.

Public health challenges

Participants identified public health challenges facing asylum seekers, categorized as immediate, intermediate, and long-term challenges. Box 1 presents a complete list of public health challenges, frequency of mention, and representative quotations.

Immediate challenges

Immediate challenges included exposure to harmful environmental conditions and inadequate infrastructure (96.7%), lack of disease control measures (86.7%), and poor sanitation (76.7%). Nearly every participant (n=29) reported unsafe environmental exposures and inadequate infrastructure. Residents lived in nylon camping-style tents, leaving them vulnerable to natural disasters including floods and hurricanes; heat exhaustion or hypothermia; and respiratory symptoms from smoke and toxin inhalation, as residents cooked over wood fires. There were no barriers to prevent flooding and no cooling, heating, or ventilation systems. Twenty-three participants (76.7%) mentioned poor access to water and sanitation. Aid groups coordinated drinking water delivery and upkeep of approximately 30 bathing stations and 80 portable toilets for 2,500 camp residents. Sanitation construction was delayed for an entire year, and still failed to meet needs for potable water (40%). Asylum seekers bathed in the river despite infection risk, and rationed water fearing heat exhaustion. Aid workers reported inadequate training to address sanitation, and that medical delivery was reactive, not preventive (n=3). For example, while they provided rehydration fluids to manage gastrointestinal infections, the poor sanitation that caused these diseases persisted (Box 1). Poor sanitation contributed to limited disease control, especially for COVID-19 (86.7%). Participants reported contact with disease vectors including

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mosquitos, flies, rats, snakes, and scorpions (53.3%), which burrowed into tents and ruined scarce food supplies. Self-isolation and social distancing for COVID-19 prevention were impossible in the densely populated encampment.

Due to resource insufficiencies, GRM only had the COVID-19 antibody test—not viral PCR (polymerase chain reaction)—meaning that health care professionals likely missed active cases, as they could not differentiate between who had cleared the virus

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and who was actively infectious.^8,18 Most health care professionals understood the futility of solely antibody testing but believed some information better than none for tracking disease burden. Asylum-seeker participants expressed a different opinion about antibody testing. They were frustrated being offered a less accurate diagnostic test which could not determine infectivity, but which would still result in their compulsory quarantine if positive. Though no deaths or hospitalizations were reported from COVID-19, six participants knew others who tested positively for antibodies.

Intermediate challenges

Participants expressed public health challenges with intermediate implications, including a lack of central leadership (13.3%), fear for personal safety (56.7%), and limited access to social determinants of good health (63.3%).

Box 1. PUBLIC HEALTH CHALLENGES FOR ASYLUM SEEKERS IN MATAMOROS, MEXICO

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Non-governmental organizations belonging to Dignity Village expressed concern over a lack of leadership among aid groups (Figure 1). No organization with international authority acted in a supervisory role, creating a services delivery vacuum that aid organizations attempted to fill. Measures necessary for humane living within a refugee camp were absent, including a population census, stable shelters, and consistent sanitation. Participants believed that these challenges could be mitigated by the presence of the United Nations (13.3%).

Aid workers reported lacking accountability and collaboration among organizations, which they believe contributed to worse health care delivery and wasted resources.

Nineteen participants cited limited safety, education, employment, and nutrition. Violence from criminal gangs increased anxieties around safety. Unprotected tents and lack of supervision left this population vulnerable to violence and theft. Women feared physical and sexual violence (n=7) and lacked faith that authorities would help if they were in danger. One-quarter were victims of stealing or harassment, and others refused to discuss such violence out of fear for reprisals from the gangs or government. Education was available to children from local NGOs but became inconsistent during COVID-19. There was a lack of employment training, despite participants' desires and experience. Food delivery was contingent upon NGOs belonging to Dignity Village and shifted to local procurement during the pandemic. Though grateful for sustenance, residents worried about the food's nutritional value and sanitary conditions (n=12). Among these intermediate challenges, asylum seekers were more likely to mention concerns of personal safety and lack of access to the social determinants of good health such as education and nutrition. Health care workers were more likely to express frustration over lack of coordination among aid groups.

Long-term challenges

Participants perceived longitudinal effects from these challenges which could be harmful, including detrimental childhood development (93.3%) and mental health effects (83.3%). Nearly all participants (93.3%) expressed concern regarding the impact on long-term development for the approximately 500 children in the camp. They cited traumatic experiences including physical violence, sexual abuse, neglect, increased stressors, and separation from family which they believed most children in the camp had experienced. Additionally, more than 80% (n=23) of participants perceived detrimental mental health effects from these public health conditions. Participants reported worsening anxieties, sadness, frustration, feeling overwhelmed, and difficulty sleeping from living in these conditions. Health care professionals were more clinical than asylum seekers in their assessments, as they believed these symptoms corresponded with diagnoses of post-traumatic stress disorder (PTSD), depression, and anxiety. Suspension of the asylum process due to COVID-19 and MPP exacerbated these mental health conditions, creating uncertainty on when asylum seekers would receive decisions.

Health care access barriers

Beyond public health challenges, asylum seekers faced challenges accessing health care services, which were categorized by immediate, intermediate, and long-term barriers. These themes emerged during the interviews and encompassed a wide range of the health care seeking process, including lacking continuity of care (90%), resource insufficiencies (80%), gaps in emergency services (76.7%), and interpersonal barriers (73.3%). A complete list of health care access barriers, percentages, and quotations is available in Box 2.

Immediate barriers

Participants cited barriers which affected their immediate access to health care. These included resource insufficiencies (80%), limited emergency services (76.7%), inconsistent access to Mexican health care institutions (66.7%), financial barriers (53.3%), and language barriers (26.7%). Resource insufficiencies included limited health care personnel (70%), diagnostic equipment (60%), and medications (56.7%). These shortages restricted the diagnostic and treatment abilities of GRM and MSF, the medical NGOs operating within the Matamoros camp. There was a high demand for referrals to specialist health care professionals due to complex conditions, but these were often impossible due to financial and training limitations. Most aid workers in the camp were trained in primary care, and referrals to Mexican specialists were inaccessible due to finances. Though telemedicine permitted remote evaluations with some specialties, in-person consultations and procedures were inaccessible. No organizations offered dental services, and most children had not been evaluated for oral hygiene:

There are many dental caries and other complex needs; the other day I saw a kid who needs to be evaluated by a pediatric gastroenterologist, but we don't have access to that type of specialist. From our side it's hard due to limited resources. Things obviously like limited meds, limited devices, limited referrals, limited specialists, and imaging.

—Male physician, U.S. aid worker

Box 2. HEALTH CARE ACCESS BARRIERS FOR ASYLUM SEEKERS IN MATAMOROS, MEXICO

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Resource insufficiencies affected diagnostic abilities. Though the camp had ultrasound and X-ray, there was no CT, MRI, or laboratory for metabolic or blood testing. Compared with asylum seekers, health care professionals were more likely to mention diagnostic imaging and laboratory testing as a crucial limitation affecting their ability to deliver care.

Twenty-three participants (76.7%) reported lacking emergency care access. The Red Cross provided ambulatory services, but often delayed by hours. Dignity Village NGOs collaborated on emergency transportation, but no formal system existed for stabilization and transfer. No health care services were available at night, and all interviewed asylum seekers were unsure how they would manage a medical emergency. Nearly one-third recounted needing emergency health care due to fall injuries, or bleeding from lacerations or miscarriages, but confronting delays when seeking care for these emergencies. Participants recommended nightly staffing with medical personnel and training residents of the camp in first aid as a solution to handle morbidity from lack of emergency care.

From within the camp, GRM and MSF provided physical and mental health care for acute conditions. However, health institutions outside the camp in Matamoros were rarely accessible to asylum seekers (60%). Reasons included financial barriers to private services (53.3%), as private clinics and pharmacies were unavailable to those who could not pay. While some occasionally purchased generic pain relievers, medicines for chronic conditions, hospitalizations, and surgeries were inaccessible. Mexico's public health system provides subsidized health care; however, care beyond emergency stabilization was unavailable to non-citizens.

It's hard for asylum seekers to use health care in Matamoros because without insurance they need to pay completely for appointments, and they are costly. They pay for everything, and from their own pocket. Most don't have this income.—Male physician, asylum seeker

Finally, asylum seekers mentioned language as a barrier to receiving medical care within the Matamoros camp. Eight participants reported that few aid workers spoke Spanish, and that although translators were available, participants often felt misunderstood and that health care encounters frequently resulted in inappropriate diagnoses and treatment. Asylum seekers were more likely than health care worker participants to mention this barrier.

Intermediate barriers

Asylum-seeker and health care worker participants cited barriers affecting intermediate access to health care services in the Matamoros camp. These included interpersonal barriers of distrust and discrimination (73.3%), no insurance (36.7%), and missing documentation (20%). Participants reported interpersonal barriers which affected health care access (73.3%). The most frequently mentioned was distrust of medical institutions (70%). Health care providers believed that nearly every asylum seeker had traumatic experiences, which could lead to distrust of formal institutions including medical facilities. Asylum seekers agreed that many of them had feelings of distrust but reported it to be due to past experiences of ineffective medical treatment by health care institutions.

[Asylum seekers] were afraid to give their information…When people with chronic conditions come to be evaluated and you tell them we're going to do some tests they have many questions: "Where are you going to take me?" It takes a while to form trust and when the organizations break this trust, it is hard to get back.—Female medical translator, asylum seeker

Both asylum-seeker and health care professional participants cited the COVID-19 pandemic as a nexus of distrust for asylum seekers towards health care. One source for the distrust is that medical NGOs operating in the camp took restrictive steps to disease containment, including compulsory quarantine, with insufficient community education about the need for COVID-19 positive patients to isolate to reduce transmission.

Asylum seekers experienced discrimination from Mexican citizens and health care personnel when attempting to access Mexican hospitals or pharmacies (46.7%), as they were perceived as a threat to scarce resources. Three asylum seekers expressed concern about being refused care in emergency situations. Related to this fear, twenty percent of participants lacked identity documentation such as a passport, home country identification (ID), residency visa, or asylum registration card. This compounded the difficulty for asylum seekers to obtain medications, diagnostic tests, or consultations with Mexican health care institutions, as identification documents were often necessary to access these services.

Long-term barriers

Asylum seekers and health care professionals reported longterm barriers to health care access in the Matamoros camp. These included a lack of continuity of care in a complete health system (90%), lacking health records (20%), and further interpersonal barriers including beliefs concerning health care rights (13.3%) and power dynamics between asylum seekers and providers (10%). Asylum seekers lacked the benefits of affiliation to a complete health system, which could care for their health needs in a comprehensive way. Benefits mentioned included preventive care (53.3%), management of chronic conditions (43.3%), prenatal and pregnancy care (36.7%), and building long-term caregiver-patient relationships (20%).

Sixteen participants reported no opportunities for preventive care including health maintenance exams, which was especially detrimental to vulnerable groups including pregnant women, children, and those with chronic conditions. There was no access to prenatal vitamins or pregnancy education (36.7%), which health care providers believed led to miscarriages and increased utilization of emergency services in labor. Global Response Management lacked consistent access to medications to manage chronic conditions, including asthma, diabetes, and hypertension (56.7%). Medicines were occasionally available through donors, but access was never guaranteed. Participants with chronic conditions reported forgoing or splitting doses for fear of decreased access (n=5), and four respondents mentioned exacerbated symptoms from not being able to manage their chronic diseases. Health care providers worried about irreversibly worsening health care status from chronic conditions. They believed not managing chronic diseases proactively could place increased burden on the U.S. health care system as asylum seekers entered the U.S. and used public and emergency services.

Not being part of a complete health system meant that quality aspects of care, including a health record and long-term physician-patient relationships, were lacking for asylum seekers. Health care worker participants especially expressed frustration with not having an electronic medical record where they could access patients' past medical history:

Most come without any medical history, so we need to start from zero. They have never seen a doctor, even those who have given birth multiple times. It is hard for them to track their wellness, and this impacts their health and ability to work with us.—Male physician, asylum seeker

Related, as medical NGOs often relied on short-term volunteers, asylum-seeker participants lamented the difficulty of creating long-term relationships with health care professionals and their health institutions. Participants believed that by ameliorating this challenge, institutions could help combat the distrust asylum seekers reported towards health care professionals:

We've had situations where a patient will be seen, but they weren't happy with the result. Thinking maybe they got shorted if they were expecting to get a medication or specific treatment. Rather than recognizing this is the right thing, they will come back to get another provider. Of course, people seek second opinions on stuff all the time in the States. But it has made us realize that there is a little bit of a trust issue.

—Male nurse, U.S. aid worker

Another long-term barrier included power dynamics between asylum seekers and NGOs providing medical care. Residents felt they could not demand quality services for fear of appearing ungrateful for what was available, even if these services were not adequate. Asylum seekers worried that by expressing dissatisfaction, these services could be revoked. This fear prevented asylum seekers and health care professionals from approaching clinical encounters through shared decision making and patient-centered health care. For a few asylum seekers, this power dynamic went so far that they were unsure of their right to health care while living in the camp (n=4). Though health care workers were more likely to explicitly identify power dynamics as a barrier between these groups, asylum seekers more commonly used language that reflected a personal hesitance to criticize NGOs for fear of losing access to the services they provided. Finally, asylum seekers occasionally delayed seeking health care even when available, viewing their stay in Matamoros as transient. Some asylum seekers worried that by increasing their access to health care, they would be losing access to legal services to process their asylum claims. Here, there was a large difference in understanding between health care worker and asylum-seeker participants. Health care workers did not understand how such services were mutually exclusive, and expressed the view that health care should be a priority service offered in the Matamoros camp, while every asylum seeker stated their priority was entering the United States, even above health (n=24).

Discussion

This study described the immediate, intermediate, and long-term public health challenges and health care access barriers faced by asylum seekers in Matamoros, Mexico which resulted from the Migrant Protection Protocols and border closure. Public health challenges, including environmental exposures and inadequate infrastructure, poor sanitation and disease control, and limited access to the social determinants of good health led to increased physical and mental health needs among asylum seekers. Most participants expressed developmental concerns for the 500 children in the camp, given exposures to trauma and lack of education. Asylum seekers reported increases in mental health symptoms consistent with anxiety, depression, and PTSD. These findings are corroborated by independent reports from Human Rights Watch and Physicians for Human Rights, which document significant violence, rights abuses, and deterioration of health under MPP.^6,19

Barriers prevented asylum seekers from accessing care throughout all phases of health care seeking. These included lack of continuity of care and emergency services, resource insufficiencies, and interpersonal barriers. While aid organizations worked to address these challenges, they lacked authority to solve them systemically. Living conditions were unacceptable by international standards,²⁰ and the absence of the United Nations contributed to wasted resources, inconsistent communication among groups, and no supervision or accountability. Additionally, MPP appears to violate the Trafficking Victims Protection Act.²¹ While medical data across the U.S.-Mexico border is scarce, health care access barriers identified in Nogales, Juárez, and Nuevo Laredo included lack of specialists, financial barriers, and xenophobia from Mexican providers, which especially affected pregnant women (6% of population) and those with chronic conditions (8%).²² Asylum-seeker and health care worker participants shared overwhelmingly congruent perspectives on public health and health care challenges. Areas of divergence included methods for COVID-19 testing and disease containment, a lack of diagnostic equipment and electronic medical records, and the priority of health compared with legal services. Despite these few differences, the largely consistent findings demonstrate that incorporating both asylum-seeker and health professional perspectives could be valuable in conducting health needs assessments at the U.S.-Mexico border.

Macro factors including economics, labor, violence, climate, war, and instability all influence migration. However, asylum seekers constitute a marked subset of migrants: those fleeing violence and persecution.²³ Accumulated stresses over time and multiple traumas, such as those presented in this study, affect the long-term well-being of asylum seekers, and can have secondary effects with life-long health implications.^11,24 Asylum seekers face public health and health care access barriers not only through their migration journeys, but following resettlement if asylum is granted. Children are at increased risk for physical, developmental, and behavioral health challenges, and patients report difficulty finding appropriate translation, specialty, and preventive care and mental health services.²⁵ Policy aimed at protecting asylum seekers could provide significant health benefits for this vulnerable population.

Policy recommendations

There are tangible policy recommendations to improve public health and health care access for asylum seekers at the U.S.-Mexico border. These include establishing safeguards to prevent the Migrant Protection Protocols (MPP) and other inhumane policies from being implemented in the future, collaborating with the United Nations High Commissioner for Refugees (UNHCR) to oversee border crises, and addressing adverse health effects stemming from immigration policies with creative community-based alternatives.

Our findings demonstrate significant health harms from MPP and border closure, which were policies implemented under the justification of public health protectionism, but which were policies not based in political precedent or evidence of improving public health or disease containment. Bipartisan immigration and asylum reform is needed in the U.S., but local and federal policies should be designed with safeguards for human dignity. There are more humane and safer alternatives than deportations and MPP, including allowing applicants to await their claims with contacts in the U.S while following with case management. One study demonstrated that 92% of asylum seekers have family or friends in the U.S., and 97% arrive for court dates when represented by legal counsel.²⁶ Allowing asylum seekers to self-quarantine with U.S. contacts provides a safer alternative to tent encampments or congregate detention centers and could prevent future humanitarian crises while also reducing COVID-19 transmission.

Closing the border only to asylum seekers was never justified on public health grounds.²⁷ However, if border closure were necessary in the future, the U.S. could learn from this experience and avoid detrimental health care challenges through early international coordination. Inviting UNHCR and humanitarian organizations with the authority, expertise, and resources to oversee the implementation of such policies would secure adequate health care, housing, and sanitation for asylum seekers. At minimum, the U.S. should collaborate with the Mexican government to provide appropriate health care, a collaboration that would have prevented some of the challenges identified by our sample.

The U.S. must promote policies to understand and proactively address the possibly long-lasting and significant health problems it created through border closure and MPP. While the Biden administration established a commission to review the effects of MPP,²⁸ policies are needed to create more humane processing pathways for asylum seekers with exacerbated physical and mental health conditions. This includes ending congregate detention in Immigration and Customs Enforcement (ICE) facilities, as there is abundant evidence on the detrimental effects of detention on mental and physical health.^29–30 Instead, asylum seekers could await their trials with family or in shelters run by church and community organizations. This could significantly reduce harmful mental health effects due to U.S. immigration policy and limit COVID-19 transmission through self-quarantine. Such a model piloted by Immigration and Customs Enforcement has already been successful but is no longer operational.³¹

Asylum seekers are deeply traumatized from their camp experiences and will require additional resources for their care.¹⁹ Support should be offered to federally qualified and community health centers where asylum seekers are likely to access health care. Community engagement through preventive care programs such as community health workers and promotores, who are lay Spanish-speaking health workers providing basic health care services and orientation to the health system, could provide primary care to asylum seekers. Such programs have been effective in managing chronic diseases in a cost-effective way along the U.S.-Mexico border,³² and could increase trust with public institutions. It is possible to provide health screenings for asylum seekers upon their entry to the U.S., as is being done for the thousands of travelers regularly crossing the border. Strengthening public health surveillance, supporting reception locations, and providing health information at appropriate literacy levels could increase access.³³ The need to address the harms asylum seekers have experienced is undeniable. As these are the direct result of U.S. policies, there is a responsibility for the U.S. government to support mental health, health care, and social services to ameliorate the sequelae from these policies.

Limitations

This study had several limitations. Our study presents specific findings unique to one location and temporal period, and the small sample size limits generalizability. However, these qualitative findings could help guide targeted research among larger populations of asylum seekers, and our findings of the social determinants of health within migration, medical mistrust, and humanitarian services leadership and coordination fit with widespread findings from similar research. A few Haitian residents from the camp spoke Creole and could not be interviewed for the study; however, more than 95% of camp residents were Spanish-speaking and eligible to participate. Staff from Médicos Sin Fronteras did not participate, potentially limiting findings on mental health. Research on humanitarian settings faces the challenge of rapidly changing situations, which we addressed through member-checking with local experts. Finally, analyzing quantitative data could provide additional insights to complement our findings. Especially interesting would be comparing health care service utilization preceding and following the COVID-19 border closure in March 2020 to determine this policy's effect on population health.

Conclusion

This study reports the perspectives of asylum seekers and health care professionals whose health care needs and access have been significantly affected by U.S. immigration policy, particularly MPP and COVID-19 border closure. Our findings demonstrate significant public health challenges and health care access barriers that affect nearly all aspects of life and the health care process for asylum seekers in the Matamoros camp at the U.S.-Mexico border. Policy recommendations to ameliorate these challenges include outlawing MPP and similar immigration policies that lack health protection provisions for asylum seekers, inviting UNHCR to oversee this crisis, and reforming the asylum process with more humane options including communitybased programming. More research is needed to evaluate the long-term effects that such policies can have on the well-being of asylum seekers and interventions to address detrimental health outcomes.

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