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In 1994, at the tail end of the genocide in Rwanda, I headed to the border of the country to work as a physician at a sprawling camp of 170,000 refugees. The camp aimed to meet refugees’ basic needs: water, food, shelter, and medical care.

As refugees arrived, I examined them and triaged them to one of many tents depending on their health needs, where they were treated for cholera, malaria, meningitis, and other health issues needing immediate attention.


This effort was well-coordinated and efficient. While the original death toll was high when the camps were being established, the public health inside the camp and in the surrounding communities was largely preserved, thanks to the many organizations that worked collaboratively to assure the health needs of refugees were met.

Things could have gone better, but they could also have gone much worse.

Fast-forward a quarter-century and spin the globe to the United States. Last month, U.S. Customs and Border Protection declined to provide the influenza vaccine to refugees under its care in border detention facilities, saying that CBP maintains only short-term facilities and so isn’t responsible for migrants’ long-term health needs, like preventive care. Yet at least three children have died of influenza, a vaccine-preventable infectious disease, while in CBP custody.


With the Trump administration’s proposal to rescind the 1997 Flores Settlement — which requires the government to release asylum-seeking children from detention without unnecessary delay to their parents, other adult relatives, or licensed programs — codifying what appeared to be a fairly routine flouting of the limit, it is now unclear how long a child will stay in detention facilities before being transferred to the Office of Refugee Resettlement. It could be months.

It is dangerous and unethical to extend the length of detention without preparing for the health consequences of longer stays in crowded facilities that were designed for short-term residency.

If the Trump administration is formally changing how long children and families seeking asylum will stay in detention facilities, then it needs to urgently, immediately, and transparently revise its medical protocol for those forced to live in these facilities to protect public health and provide basic humanitarian aid, just as was done in refugee camps decades ago and thousands of miles away. This includes basic vaccinations as well as providing culturally responsive medical care. It will be expensive, but it is an absolutely essential step if children are to be detained for long periods of time.

I am not suggesting that detention is an appropriate place for children. It isn’t. Detaining children is detrimental to their short- and long-term health. My organization, Migrant Clinicians Network, has joined dozens of other health organizations in opposing detention for children.

The best immediate course of action to preserve public health and assure that the basic human rights of asylum seekers are met is to retain the Flores Settlement and keep detention of children to a minimum — make it a time for administrative processing and providing basic medical screening before transfer to the Office of Refugee Resettlement and then on to community-based resettlement.

With such a process we can respect the basic human rights of those crossing the border and follow internationally recognized processes for asylum seekers while beginning to address the compounding layers of trauma that migrant children have brought with them. It will also prevent deaths.

The Trump administration has demonstrated yet again that it prefers to make changes to immigration policies designed to protect public health in centers of detention without considering the consequences of such changes to the health of detainees and also, it follows, to the public at large. Separating children from their parents, overcrowding facilities to the point that temporary outdoor fencing with concrete flooring and no beds was deemed appropriate as a facility, and declining to provide basic sanitation measures like soap have resulted in infection, sickness, and death. If long-term detention is combined with lack of vaccinations for communicable diseases in such already overcrowded facilities, even more infection, sickness, and death will follow.

The administration’s dangerous and short-sighted shift to longer-term detention needs to be urgently reeled back. It will jeopardize the health and well-being of migrant children in our care — and will likely result in more deaths.

Laszlo Madaras, M.D., is the chief medical officer of the Migrant Clinicians Network, a family physician in Pennsylvania, and a clinical assistant professor of medicine at Penn State College of Medicine.