When the patient arrived in the emergency room, he was distraught. His brother had been killed while migrating through Central America, leaving him to cross the U.S.-Mexico border alone.

“He was getting emergency room-level care, but the thing that was eating away at him nobody was acknowledging,” said Jennifer Smith, formerly a doctor at a border hospital but now practicing at Chiricahua Community Health Center, Inc., in Arizona.

People coming from Central and South America frequently pass through some of the most dangerous migration routes in the world. Violence, robberies, kidnappings, and sexual abuse are pervasive threats. Many people sustain physical injuries and experience illness on the journey. 

“There is an idea that coming to the United States is somehow better than what they are coming from. And maybe it is, but I’m not a hundred percent sold on that,” said Rose Lira-Ostrea, the director of Behavioral Health at Su Clinica in Harlingen, Texas. “What they have to endure in the process of getting here is…inhumane,” she said. 

Su Clinica, a federally qualified health center, is located 17 miles from the U.S.-Mexico border. Many of the patients they serve are recent migrants from Central and South America who have experienced trauma during their journeys. Basic primary care appointments, such as children’s vaccinations, often turn into mental health interventions. 

Su Clinica is one of 25 federally qualified health centers in the state of Texas that has received training in trauma-informed care through the Texas Association of Community Health Centers (TACHC) and with funding from Direct Relief.

Caring for trauma

The program was conceived in 2018 in response to the influx of unaccompanied minors crossing the U.S.-Mexico border.

“When we saw that the children needed support, the families needed support, the staff needed support, we took a step back and thought, you know, these kids are probably going to end up in our health centers – which they did,” said Dr. Roxana Cruz, the director of Medical and Clinical Affairs at the Texas Association of Community Health Centers.

Since 2019, TACHC has trained over 400 health care providers throughout the state of Texas in trauma-informed care practices. 

The core assumption of trauma-informed care is that any patient may have been exposed to trauma at some point in their life, whether in childhood or as an adult, explained Cruz. The objective is to create a safe environment for the patient to receive care, one in which they feel comfortable returning.

“It’s a framework where we help our staff understand and be able to respond to that impact of trauma. We are thinking about physical, psychological, and cultural safety for everybody,” said Aimee Rachel, a licensed master social worker and the trauma-informed care coordinator at TACHC. “That is the most important thing.” 

In some cases, experiences of trauma can make patients uncomfortable in a medical setting and cause them to delay health care. “Maybe the patient has missed five appointments because the last time she had a Pap smear they were not considerate with her and it reminds her of the abuse that she went through when she was a child,” explained Priscilla Bernal, the Director of Social Services at Su Clinica.

Providers at Su Clinica are careful to explain procedures in the patient’s language and ask patients’ permission before proceeding – a hallmark of trauma-informed care. 

Thousands of stories

At Su Clinica, behavioral health and social services are often provided during medical appointments. At their women’s clinic, for example, patients come for gynecological care but often reveal to their medical providers that they are also experiencing domestic violence at home.

Many of these women are particularly vulnerable to abuse due to their legal status. “They’re being threatened by the spouses saying, ‘If you call the police on me, I will deport you to Mexico. So be very careful with what you do,’” explained Bernal. 

In this case, the medical provider can bring Bernal into the appointment to provide supportive social service resources. This can include paying for the patient to stay in a motel room for a few nights, directing them to women’s shelters, and providing them with contact information for organizations that provide advice and emergency support. The health center has designed a discreet pamphlet with these phone numbers hidden among other contacts since many women face reprisal for reporting abuse. “We have to get very savvy to give them that resource,” Bernal said. 

In addition to rape and sexual assault, women and children are at higher risk of being victims of human trafficking, for both sex and labor. In 2019, Texas reported the second-highest number of cases of human trafficking in the nation, according to the National Human Trafficking Hotline.

Bernal recalled one of her patients who was intercepted by a sex trafficker while migrating to the U.S. to be with her children. The patient reported being kept in a barn with others for months on end: “They would give them one gallon of water per day…one group with one gallon of water.” The woman eventually escaped.

This is one of “thousands” of stories both Bernal and Lira-Ostrea have heard through their work on the border. For some, these experiences of trauma become unbearable. Lira-Ostrea has had patients tell her: “’I have been through hell and back…I would rather die than keep going through this.’” 

A Right, Not a Luxury

While many of those who have recently migrated to the U.S. are some of the most in need of health care, including mental health services, they are often the last to seek it out. 

“There’s a lot of fear of maybe being visible to authorities or being seen as causing a problem,” explained Natasha Howard, an Associate Professor of Global Health and Conflict at the London School of Hygiene. “They might just say, ‘Oh, okay. I’m not well, but I don’t even want to try, because then I have to write my name down.’” 

For many, fear of deportation is a major barrier, said Howard: “People don’t want to do anything that might jeopardize their situation.” 

Other times, securing food, shelter, and work take precedent over getting health care, especially in places where health care is costly. “Often health is – while it should be a right and according to human rights law, it is a right – it’s often sort of treated more as a luxury,” said Howard. 

This is especially true for mental health care. 

“I see a lot of my patients, they’re working very hard, they’re maybe feeding two different families they’re looking towards the future and sometimes they feel stopping and addressing their mental health to too much of a degree is too indulgent,” said Smith. 

Speaking for themselves

At Su Clinica, helping patients heal from these traumas begins by “recognizing that the situation that a patient, a person, a human finds themselves in, does not define them,” said Lira-Ostrea. 

Rather, the provider’s role is to let the patient speak for themselves: “We all at some level can recognize someone else’s needs if we allow ourselves to come from an area of recognition, allowing the person to speak, allowing them to feel safe.”