Fears stoked by President Donald Trump’s anti-immigrant statements are causing undocumented Latinos to delay or avoid seeking medical care. In a study published on October 30 in PLOS One, 24 percent of such patients said the president’s statements made them afraid to visit the hospital. And of these, half said they delayed going as a result. Others witnessed the same trend for using these services. A quarter of Latino immigrants surveyed said they knew someone who did not go to the emergency department because of his or her immigration status.

Three quarters of undocumented immigrants and 51 percent of Latino legal residents said the president’s rhetoric made them feel unsafe in the U.S. The number of patients reporting such concerns increased over the last six months of the study, during which Trump announced plans to deny green cards to immigrants who use public assistance programs such as Medicaid. It was also when he tweeted about an “onslaught of illegal aliens” and threatened to close the southern border.

“Emergency departments are really the safety net for all kinds of disenfranchised groups,” says Robert Rodriguez, an emergency medicine physician at the University of California, San Francisco, and the study’s lead author. “If these statements have created a barrier to that access, then that’s going to compromise how the system is intended to work.”

Rodriguez says he and his colleagues got the idea to do the study after they began noticing anxiety building among their patients around the time Trump was elected. In 2013 he co-authored a study in Academic Emergency Medicine that showed one in eight undocumented Latino immigrants was fearful of visiting the emergency department. “We thought it would be a good time to reassess the specific effect of rhetoric” on these patients, he says. “This study arose organically out of that.”

From June 2017 to December 2018, Rodriguez and his colleagues surveyed 452 Latino undocumented immigrants, 473 Latino legal residents and 393 non-Latino legal residents at three emergency departments in California. (Rodriguez stresses that providers were trained to avoid injecting political bias when surveying patients.)

Undocumented patients who reported delaying treatment did so for a median of two to three days. The actual numbers of undocumented immigrants avoiding emergency departments may be higher than what the study found because it only included those who did eventually seek treatment, Rodriguez says.

The results mirror findings from focus groups conducted with community health workers in Texas. In that study, published in BMC Health Services Research in June, the authors found the president’s rhetoric shaped undocumented immigrants’ access to health care. One community health worker at a clinic that serves undocumented immigrants said that after Trump threatened deportations at the end of one week, patients did not show up for scheduled appointments on the following week. Children were more at risk than adults, in part because undocumented immigrants were choosing not to renew their food-stamp, or Supplemental Nutrition Assistance Program, benefits out of fear that their immigration status would be reported to authorities if they did.

Richard Carmona, who was U.S. surgeon general from 2002 to 2006, says the issue of undocumented immigrants being afraid to pursue treatment is not new. “I think it’s certainly been exacerbated now,” Carmona says, “because when it comes from the president of the United States and from people around him, it adds fuel to the fire.”

Previous studies have also linked anti-immigrant legislation to declines in undocumented patients getting medical care. A 2001 paper published in the Journal of Immigrant Health reported that Proposition 187—a 1994 California ballot initiative that required physicians to report undocumented patients (which was later found to be unconstitutional by a federal court)—likely raised fears among undocumented patients that caused them to avoid seeking treatment. In that study, about 14 percent of respondents in California and Texas who expressed fear of being denied care because of their immigration status reported being subsequently unable to obtain medical services. And a 1996 paper in Ophthalmology found Proposition 187 resulted in a two-month dip in walk-ins at one clinic in California, although the number of patients returned to normal levels after word about the federal ruling invalidating it spread.

Even after such barriers are removed, restoring trust among affected communities is difficult, says Katherine Yun, a pediatrician and immigrant health researcher at Children’s Hospital of Philadelphia, who was not involved in these studies. In 1996 welfare reform barred newly arrived immigrants from Medicaid coverage for the first five years they were in the country. Yun says this rule led families to believe their immigration status would be compromised if they sought public benefits. Regaining patient confidence was difficult. “It took a lot of clarification and public outreach,” she says. “It can take time for people to feel safe again.”

Rodriguez and his colleagues recommended that clinics post “Know Your Rights” educational materials in multiple languages and reassure undocumented patients that they are safe. Beyond the clinic, they suggest public awareness campaigns in Spanish-language media and cooperation with neighborhood organizations and churches.

“If you get sick, and you’re undocumented, you’re incredibly vulnerable,” says Guillermina Núñez-Mchiri, a cultural anthropologist at the University of Texas at El Paso, who was also not involved in the studies. “And the majority of U.S. citizens have no idea that this is a concurrent reality in our nation. We have a moral obligation to think about how we distribute [health care] so that we can all be well. Because when a big segment of the population is not well, it hurts everybody.”