On a cool spring afternoon, in a clinic that serves refugee and immigrant families, I sit across from a teen-age girl. She is otherwise known as an unaccompanied alien child, or U.A.C. She left her home in Central America, crossed the southern border, and was detained for a week—in Texas, she thinks—in a facility where breakfast was a cold bean burrito, lunch was a cup of microwavable noodle soup, and dinner was a cold bean burrito. She says that the detention facility was fine—no, nothing bad happened. Yes, it was only girls. Her main complaint is that she was not allowed to brush her teeth.
From the detention center, she was taken to a shelter in the Pacific Northwest for such children. She remains in the custody of the Office of Refugee Resettlement (O.R.R.), waiting to hear that she has been cleared to travel on to her family members in this country. I meet her during her first seventy-two hours at the shelter, when she is brought to my clinic for an initial refugee-health screening. The shelter is fine, she says. The people are very nice.
Today, I will order a chest X-ray and a series of blood tests. I will ask her a long list of intrusive questions, and I’ll send the answers to O.R.R. I’ll tell O.R.R., for example, when her last period was. I will tell them whether she has been physically or sexually abused, and, if so, in what country. I will tell them if she has frequent headaches and whether she wishes to commit suicide, homicide, both, or neither. I will send them the results of testing for H.I.V, tuberculosis, and pregnancy.
But I am not the government. I am not ICE. I am a pediatrician. In these encounters, my colleagues and I try to make it clear that we wish these children no harm. At the same time, we must explain that our conversations are not entirely private. Every result will leave my office, leave my hands, and factor somehow—in ways I cannot know or predict—into this child’s uncertain future. Most of the cases of children seeking asylum will be denied, and the children will be deported.
I can hear other children in the hallway outside, most of whom are visiting our clinic for their routine well-child checks. A new baby is being weighed, and his mother claps her hands happily and then whispers to the baby in Somali when the medical assistant hands him back to her. You can hear pride in her voice, delight that the baby is thriving.
I begin to fill out the “family history” section of the form, and ask the girl if her parents are living. Her mother is alive and has no health conditions. Her father died. She is not sure how old he was. I have to ask how he died, and she looks at me flatly and says, “They killed him.”
I am silenced, though I have heard this sentence drop from the mouths of children before. She looks at me strangely while I pause. I have to remind myself that I will not be forming a long-term relationship with this girl. I will be her pediatrician while she is in the shelter, and that is all. I ought not make her trudge through the details of her father’s murder. So I make a mark on the form and move on.
No, she has not had surgery. She has no allergies or health conditions. She takes no medicines. She has never been sexually active. She has never been raped or physically abused.
But when I begin my exam I find scars on her arm, three long parallel lines where the skin is pale and puckered. Burns, I think. Every pediatrician knows to look for patterns in wounds: straight lines or perfect circles, bruises with the slap-marks of fingers, things a child could not have done to herself. Someone has hurt this girl, on purpose.
I ask her how it happened. I have asked this same question of dozens of children. The intent is to get their story without suggesting a cause.
“Oh,” she says, as if she had forgotten it. “They did that to me.”
When?
“When I was nine. They kidnapped me.” She explained that “they” thought her family had money because her aunt was already in the United States. She doesn’t name “them”—these torturers of children, murderers of fathers. I am not the police and do not need to know who “they” are. There is nothing I could do with that knowledge if I had it. So I simply take up her language, using the “they” form of the verbs in Spanish.
“How did this happen?” I ask. This is for documentation. I have been trained to document the sources of scars; if I document both scars that the patient says are from torture and scars which the patient says are not from torture, it supposedly lends veracity to their story in the mind of someone (I don’t know who) who will make a decision (I don’t know what) about her life.
She says she doesn’t know. They gave her a drug, she says, and it put her to sleep.
I ask her if she wants to see a counsellor who specializes in trauma. This is also, technically, off-script. Here is how I’ve been trained to explain the concept of trauma to a kid: “When kids go through something very scary like that, fear and pain can hide in their body for a long time. It can come out in ways that surprise you, making you feel scared, or angry, or lonely. Some kids feel their heart beating very fast, and some have nightmares. Our counsellors help kids work through this, so the fear and pain can leave the body and you can feel more healthy.”
Pediatricians refer to experiences that cause children severe or chronic stress as Adverse Childhood Experiences (ACEs). ACEs include exposure to violence, neglect, and sexual abuse, among many others. A burgeoning body of research in child development shows that childhood stressors can compound to affect long-term health, including the risk of diabetes, heart disease, substance abuse, and suicide in adulthood. When ACEs are severe or prolonged, they can even affect the physical structure of a kid’s brain. Trauma-focussed counselling is one of the ways we try to mitigate these effects.
But the girl declines counselling. It was a long time ago, she says. She was very upset at the time, but her mother helped her recover.
I want to hear this girl talk about her own strength, and I want to learn how a child recovers emotionally from kidnapping and torture. So I stay off-script, asking, “How did she do that?”
“We talked,” she says. She smiles, and tells me that her mother understands her very well. I believe her.
The power of mothers and fathers—families—to protect children is remarkable. When loving, consistent adults, such as this girl’s mother, are present for a kid, experiencing trauma in childhood need not be a sentence to long-term suffering and ill health; early research suggests that strong families can mitigate the effects of trauma on a child’s body, brain, and development. For example, a study published in September, in JAMA Pediatrics, describes the health effects of positive childhood experiences, such as having a parent in the home whom you trust. Researchers found that such positive experiences could reduce rates of depression and poor mental health in adulthood, including people who also score high on ACEs. Primary-care pediatricians are learning not only to screen for ACEs but to equip families with the tools they need to help kids flourish despite trauma.
The harm done to children who are separated from their families, by border policies or ICE raids or incarceration, is evil precisely because the absence of parents makes it difficult for children to recover from the trauma of the separation itself. It is a mean trick to play on a child: traumatize her by taking a parent away, then keep her from that parent—the exact person she needs in order to recover.
The girl is looking at me steadily, waiting for my next question. So I finish the mandatory questions and explain the next steps: blood test, chest X-ray, vaccines. I apologize for all the vaccines.
“Will it hurt?” she asks, and, with that question, she finally sounds like a kid.
“It will,” I say. “But we’ll do it fast, and then it will be over.”
She tells me she is scared of needles, and she fidgets in her seat.
It’s normal to be scared, but I know she is very strong, I tell her. I also know that I would not typically put a kid through so much in one visit. Typically, although I might interview a teen-ager on her own, I wouldn’t examine her without a parent in the room. But this child’s only living parent is thousands of miles away. This is the protocol; she is in the custody of O.R.R., and this clinic visit will get her one step closer to being reunited with family.
At least, that is how I explain it to myself. In these visits, my colleagues and I engage in what I have come to think of as small acts of humane resistance: we try to be patient and kind with the kids, to treat them as fully human and deeply valuable, even as violence in their home countries, conditions in our detention centers, and border policies align to insist that their lives are worthless.
Is that enough? To smile at a kid, to try to make her comfortable? Of course, it is not enough. No act of resistance is sufficient for this horror. And my efforts to distinguish myself from the government—I am not ICE; I am not ICE—feel vain.
In fact, I am within and of this system, and the ways in which I benefit from it are not at all obscure. The state of Texas paid for my medical education. The federal government funds residency training—from whence we physicians get our specialties, our incomes, the medical knowledge that crowds our minds.
I am also an ordinary American—a citizen of a nation that is incarcerating children and putting their health at risk. Some of those children have died preventable and unnecessary deaths while in our nation’s custody. This child has been sent by a loving mother who hopes that she might enjoy what so many—though certainly not all—ordinary Americans do: a chance to survive childhood, to finish school. She is a bright amalgam of hopes, flung across a hemisphere into this moment.
But, at this moment, she is also a teen-ager, and the prospect of getting shots has tipped her into misery. She looks like she wants to cry, and so, instead of leaving the room while my assistant prepares the vaccines, I stay.
I ask her what she is hoping for. I will not report this answer to the government, but after such an invasive and unhelpful interview, I scratch for something to redeem the afternoon, something to help us both feel better.
“Here?” she asks, glancing over at the scale by the sink, which is decorated with a giraffe.
“I mean here in the United States.”
And she gives the same answer that so many of my other teen-age-refugee and asylum-seeking patients give: she wants to go to school.
“And what do you want to be when you grow up?” I ask the girl.
She smiles again. “An architect,” she says.
