We interviewed a total of 28 staff members across the three sites: FQHC in Detroit (n = 12), FQHC in Washtenaw County (n = 5), Washtenaw County non-profit (n = 12). Twenty-three were bilingual English-Spanish speakers and 18 self-identified as Latino. The staff roles interviewed included medical providers, medical assistants, receptionists, enrollment specialists, patient advocates, and others.
Our analyses identified three major interrelated themes in the context of our research question: 1. An increased and pervasive fear of deportation and family separation among clients in mixed-status families; 2. fear because of the anti-immigrant climate has resulted in fractures in community cohesion; and 3. fear has had an impact on healthcare utilization and other health-related behaviors among mixed-status families in an effort to prevent deportation and protect their families. In this section, we detail each of these themes and provide illustrative quotes using pseudonyms.
Increased and pervasive fear
Universally, staff members discussed that their clients who are part of mixed-status families are experiencing more fear and anxiety related to possible deportation than before the election. Isabel, a staff member at the Detroit FQHC, succinctly summed up staff perspectives of this increased fear: “They’re fearful. They are so much more fearful now than they were 2,3,4,5,10 years ago…huge huge impact, huge difference.” Staff members across roles, location, and ethnicities spoke about how the 2016 election and the inauguration of President Trump caused mixed-status families to be fearful that a family member would be suddenly detained and deported. Most participants said that this fear has lasted, but was most acute in the immediate period after the election. Vanessa, a family medicine doctor at the Washtenaw County FQHC said:
“The time between the election and the actual inauguration, I think that was the worst cause there was a lot of ‘we have no idea what’s going to happen’ and just a lot of fear. People would just come in and say ‘I’m afraid’.”
Some staff members questioned whether the fear was due to an actual increase in deportations or attributable to anti-immigrant rhetoric and uncertainty related to policy proposals (that is, policies that had yet to be enacted). Brian, a family medicine doctor at the Detroit FQHC reflects some of these ideas in his comments. He initially points out that anti-immigrant sentiment is driving the pervasive fear: “the rhetoric that comes out from Donald Trump, I think the patients definitely feel it…it’s not even just the ones that are undocumented, I think the community feels it.” Importantly, Brian notes that he is seeing this fear across all his patients, not just those who are undocumented. In contrast, Brian said that he knew many patients who were deported during President Obama’s tenure and that certainly caused some fear in the community; however, he perceived that the impact was narrower under President Obama because immigrants who did not have a criminal record did not feel targeted to the same extent. He goes on to share that now “it just doesn’t seem like there’s any rhyme or reason” and that any immigrant could be a target. He continued: “What makes me more nervous is that the rhetoric creates fear but now the inconsistency creates more fear…[it’s] paralyzing.” Many other staff members shared this same sentiment that deportations are not new in the Trump era, but that the anti-immigrant rhetoric from politicians and uncertainty of policy decisions is driving a lot of the increased fear in their clients.
Another impact of the 2016 election is that the pervasive fear caused fractures in the communities where immigrants live. After the election, several staff reported incidents of racist or discriminatory remarks by non-immigrant clients that were aimed to make immigrants feel unwelcome in their community. Gabriella, customer service representative at the Detroit FQHC, noted that the election seemed to increase cases of overt racism or discrimination against Latino clients:
“A lot more people seem to be coming out more racist and more against the Hispanic communities. So, I think some of them [immigrants] are more like, you know, they don't wanna go out to the stores or do anything where they're gonna have that complication or be like, well, ‘where's your green card?’ or ‘where's this?’ and then they gotta be like, you know, they get nervous. I feel like sometimes, yeah, I think the election affected the community a little bit.”
Others echoed this idea that immigrants were increasingly being publicly questioned about their belonging in the U.S. Furthermore, several non-profit staff members noted an event where they had to intervene happened at their offices shortly after the election. T, an enrollment specialist at the non-profit said:
“There was a person there on the phone. They were speaking in their native language… which they had every right to do. They were not loud, they weren’t belligerent, you know, they weren’t causing a scene or being disruptive. But, yet, you have someone else that was from a different background, wasn’t very [pauses], culturally sensitive shall I say.. and she just made snide comments loud about you know people talking in different languages they need to talk, you know, English. And, it’s like, wait a minute, hold up, we accept everyone here no matter what language they speak or what nationality they are or how much money they have. You know that person was in the wrong. It was just wrong.”
This event reflected that some of the existing racist fractures within this community were augmented and exacerbated by the political climate during the election and afterwards. According to several staff members interviewed, non-immigrants were increasingly willing to verbally harass immigrants who were non-white or spoke another language. Increased threat of such incidents resulted in greater fear among mixed-status families for two reasons: (a) they feared being harassed in public and sought to avoid such instances, and (b) they were concerned that a racist community member could report them to the police or immigration enforcement.
The election and resulting policies also created fractures within immigrant communities that increased fear and anxiety. Cohesion within immigrant communities was affected because people were afraid that associating with someone who has been contacted by ICE would make them more likely to be targeted for deportation. As Jennifer, a patient advocate at the Washtenaw County FQHC describes: “So, after a family member has been detained by ICE, that family is seen in a way as tainted. So, their communication and their contact with other community members, family members, friends, they’re are kind of like the plagued family. ‘Oh, ICE has been to that house, we are not going to associate with them anymore.’” Thus, the fear is located within their own community as well. This demonstrates the pervasiveness of this fear as some mixed-status family members perceive that associating with certain neighbors and friends could make it more likely they are deported or separated from their family.
Impact on healthcare utilization and other health-related behaviors
Because of this exacerbated fear and sense of exclusion, staff reported that immigrant families are adopting certain behaviors to limit the possibility of deportation and family separation. The most frequently discussed change resulting from the fear was that members of mixed-status families were increasingly avoiding social services and clinics. Staff members at each site reported that immediately following the election, there was a decrease in the number of immigrant clients coming for health or social services. Several participants noted that their waiting rooms--previously filled with immigrant clients--were emptier in the weeks after the 2016 election. T, an enrollment specialist at the non-profit, described what she remembered from that time period:
“Once elections took place and we had a new president in place, you had clients that weren’t coming. I mean, the office was again literally empty, for a couple of weeks at least, because people were afraid to come in. I remember having someone here in tears, I mean literally in tears, because she was afraid to come out, you know, and she finally came. She made that step and she came. But, next she was worried about getting home safe you know.”
Similar to T, many others noted that the cancellations and no-shows in November 2016–February 2017 were particularly noticeable. They suspected it was related to the uncertainty of what might happen and the immediate policy changes, such as the ban on travel from certain countries, that followed the inauguration. This effect was noticeable across settings, but staff reported that attendance increased and approached average rates over the next few months.
In addition to the immediate post-election effects on behaviors related to seeking health or social services, staff also noted an increase in no-shows or cancelled appointments when an immigration enforcement action had recently occurred in the community. Martha, a receptionist at the Washtenaw County FQHC, recalled a patient who had called her to cancel an appointment:
“[I] had a lady that she was very honest. She was like, ‘I’m not going out, I heard that, my grandson told me that immigration is doing a round and I’d rather just stay home.’…That kinda like, I never spoke about it, I never recorded anything, that was a shock to me. I was just like, ‘wow’ and she’s like, ‘yeah I’m just going to call back to reschedule.’”
This exemplifies that clients are primed with fear and an indication that their safety may be threatened—such as immigration enforcement actions nearby--caused them to consider avoiding the clinic or social services.
Sometimes the fear and changed behavior was not in direct response to an enforcement action or the inauguration but moreso just generalized fear—or ‘paralysis’ like Brian mentioned--that affected health-care seeking. One of the Community Health Workers at CHASS works with diabetes patients and believes that many of her clients’ diabetes management has suffered in the post-election period.
“I have a patient that barely ever leaves her house. She’s just scared, she’s really scared…[the fear] makes their [A1C] numbers go through the roof. Because they’re stressed out all the time. They’re always looking over their shoulder…sometimes they’ll go a week or two without medication because they don’t feel safe enough to come out.”
In addition to this example from a diabetes patient, another staff member noted that many of their pregnant patients feel unable to attend prenatal appointments because they do not feel safe traveling to and from the clinic. Laura is a referral coordinator at the Detroit FQHC and recounts her frustrations trying to get pregnant women in for their prenatal appointments:
“It’s very hard. We’ve been seeing a change in this past year with us scheduling these appointments. Patients that need these ultrasounds…They’re constantly not showing up for their ultrasounds. They’re rescheduling and everything, it’s because, you know, of the immigration status right now. They’re scared to drive, most of these ladies have an expired driver’s license for years and they don’t want to risk it. They don’t even want to risk coming to the clinic anymore because they don’t have no other transportation but theirselves and they’re scared to get out there in the street with an expired driver’s license cause they hear that the immigration is out a lot more than ever.”
The aforementioned examples clearly illustrate the direct relationship between increased fear (generalized or targeted) and healthcare utilization, potentially resulting in worse health outcomes. In many cases, this is partly due to state-level policies that inhibit undocumented individuals from obtaining a driver’s license and thus make travelling by car more difficult. For the Community Health Worker’s client with diabetes, the decision to adopt behaviors that would protect herself from deportation and separation from her family (i.e. staying inside her house) resulted in poor health outcomes. For Laura’s clients, it resulted in avoiding prenatal care, a service that is effective in the prevention of poor maternal and child health outcomes.
Staff perceived that the fear also had an impact on utilization of public benefits. Among staff members that worked on enrolling immigrant clients in social services or public benefits, many reported that clients were less willing to enroll in government services for fear of exposing themselves to the federal government. Principally, the concern was that providing their address and contact information might allow ICE to find them and deport them. Additionally, given that the Trump administration proposed that immigrants who received public benefits would be prohibited from having a visa or obtaining citizenship—and there were rumors about this before it was officially proposed--some immigrant clients chose to avoid such services to retain the possibility of a more secure place in the U.S. through a visa or citizenship. Jimena is the WIC specialist at the Detroit FQHC and she describes these concerns:
“We help them a lot with their income, we help them with services like Medicaid. WIC is a very important for them, well, it was…Back in the year or so they stopped coming to their appointments. We have clients who would call us and tell us they don’t want nothing to do with WIC only because of immigration.”
Among staff that worked more intimately with immigrant families (i.e. case workers, community health workers), they heard that some of the behavior changes also affected elements of health beyond utilization of clinic or social services. For example, Adriana, a Community Health Worker in Detroit, details how this fear and anxiety related to family separation could affect food insecurity:
“I think that there's a real fear of being stopped. Of being, you know, just the fact that racial profiling does exist, you know, feeling like you always have to look over your shoulder. Those things really do affect how people function. There are people like I mentioned, you know, they're stressed. They're depressed. They have anxiety. People that don't want to come out of their house. People that are afraid to go shopping for groceries because they don't want to put themselves at risk.”
Mia, working as an enrollment specialist at the non-profit, echoed similar issues with the families she worked with.
“I had another family that what they do is, like, they go food shopping once a week…they get as much as they can...they are in their home and they only go out to take the kids to school or to work…and if they run out of food in the middle of the week for whatever reason they have to wait…the kids have to wait…you’re a child and you like can’t eat anything. Food has run out and your parents are telling you ‘well we have to wait.’”
Both of these quotes reflect that the fear in the post-election period is impacting immigrant families’ ability to get food and is potentially causing food insecurity for some families. In addition to food insecurity, we heard from staff that immigrant families are avoiding recreation at public parks and avoiding certain public social events. These decisions, made to limit exposure to the possibility of deportation, have a potential impact on mental and physical health.
Finally, the fear created new issues that staff were needing to respond to. Participants noted that clients were trying to prepare for possible deportation or detention by asking health and social service providers about arranging for power of attorney and ensuring their children would be safely cared for if they were deported. Isabel is a patient advocate at the Detroit FQHC and had lot of experience with her clients asking about power of attorney:
“We saw in the beginning, what I would say from the inauguration till probably all last year, especially the first 6 months, all kind of letters and affidavits giving, guardianship and just people’s rights to a neighbor. Sometimes you don’t even know these people, and they’re giving kids to them. because their kids are U.S. citizens and the neighbors are U.S. citizens. [They say] ‘if they come for me I just want to make sure my kids are ok.’ They don’t even really know these people!”
These types of power of attorney documents giving parental rights to other adults need to be renewed every 6 months. Staff members—particularly those bilingual and bicultural staff members who were seen as a community resource--shared that this is an issue that they are continually asked about. They noted that while power of attorney documents could help children in the case of a deportation, it also served as an added burden for staff and a chronic stressor for parents who were reminded that they could be removed at any moment from their children.