On August 3, 2019, a white supremacist with an AK-47 opened fire on shoppers in an El Paso Walmart, killing 22 people, including a 15-year-old, and wounding scores more, including a 9-year-old and a 2-year-old. Parents and grandparents died protecting their children and grandchildren. That Latinos were the gunman’s targets was clear from the site he chose, survivors’ observations, and his own confession. Minutes before the massacre, he had posted online a 2300-word anti-immigrant screed referring to the “Hispanic invasion” and expressing the fear that white people were being “replaced” by “foreigners.”

The attack was the deadliest of those targeting Latinos in recent U.S. history. It follows several years of President Donald Trump and his media allies demonizing Mexicans and Latinos (as “drug dealers,” “criminals,” “killers,” “rapists,” and “animals”) and describing the arrival of asylum-seeking families as an “invasion” by people coming to “replace” us — language echoed by the El Paso killer.

The U.S. government has also mounted sustained attacks on these families by means of policies and actions of the Department of Homeland Security (DHS) and the Department of Health and Human Services Office of Refugee Resettlement (DHHS-ORR) and executive orders of the President.

In the past year, for the first time in nearly a decade, children have been dying in DHS and DHHS custody. Six Central American children (ranging from 2½ to 16 years old) died between December 2018 and May 2019, most of them in Customs and Border Protection (CBP) facilities. A 19-month-old girl died in August 2018, shortly after discharge from the Dilley Family Detention Center in Texas; as past president of the American Academy of Pediatrics, I reviewed her medical records and can testify that despite her mother’s repeated requests, she was not seen by a doctor. After being discharged without appropriate medical evaluation, she was acutely ill on arrival at her destination hours later and died within weeks.

We all know about the administration’s horrific Zero Tolerance Policy, which has resulted in children being ripped out of their parents’ arms. We’ve also heard about the deplorable conditions in CBP detention centers, where children are not given adequate food, sit in soiled diapers for days or longer, sleep on concrete floors with lights left on 24/7, are exposed to infections in close quarters without adequate hygiene or medical care, and are physically and sexually abused.1 But myriad policies are inflicting further harm on migrant children.

First, although family separation officially ended over a year ago,1 many children are still being separated from their parents at the border and sent to DHHS-ORR shelters. Parents crossing the border can be charged with a misdemeanor, labeled as criminals, and have their children taken away from them. Children arriving with a grandparent, adult sibling, or other relative who may have been raising them, and is now acting in the role of a parent, are also frequently separated from that adult. The American Civil Liberties Union estimates that nearly 1000 children have been taken away from parents since last summer — probably a significant underestimate, but we don’t know the exact number because the process is opaque to health care providers, advocates, lawyers, and the media.

Second, in a cruel attempt to prevent families seeking asylum at legal ports of entry from crossing into the United States, the administration has started a “metering” process officially known as the DHS Migrant Protection Protocols. Under this policy, hundreds of asylum seekers must wait in Mexico for weeks or months, while a few are allowed across the border each week. These families are living in squalid, dangerous conditions, and many eventually risk crossing into the United States in between ports of entry. More than 100 people have drowned during this past year trying to cross the Rio Grande, among them parents with little children.2

Third, the ORR shelter system, which was previously more humane than CBP or family detention centers, has rapidly expanded; large warehouse centers, including one in Homestead, Florida, and a now-closed tent city in Tornillo, Texas, as well as many small shelters have been opened with little training or oversight of the shelter staff. The need for such vast shelter space is a problem the government itself created by removing children from families and instituting more arduous requirements for their prospective sponsors, leading to longer shelter stays and a clogged pipeline. There have been numerous reports of children being sexually assaulted while in the care of ORR subcontractors, sometimes by staff. Pediatricians and advocates are no longer allowed into the shelters to see what’s going on.

Fourth, the administration has relentlessly issued punitive executive orders and rules. One regulation, published in the Federal Register on August 12, 2019, and due to be implemented this fall, redefines what constitutes a public charge; it has caused many families to forgo benefits to which they or their children, most of whom are U.S. citizens, are legally entitled. On August 21, the administration issued a regulation to replace the 1997 Flores agreement, which limited the amount of time migrant children could be held in custody to a couple of weeks and mandated provision of care equivalent to that of state-licensed child-care facilities, including a safe physical environment, adequate nutrition, appropriate medical care, and educational and recreational services. The new rule would enable the government to detain children indefinitely and would allow it to decide how much care to provide. The rule is being challenged in the courts.1,3 The administration is also seeking to restrict housing assistance for families with mixed citizenship status; more than 50,000 children would probably be affected, possibly becoming homeless. And rules are being developed to require U.S. citizens to reimburse the government for the use of means-tested programs (such as the Child Health Insurance Program) by immigrant relatives, including children, whom they sponsored.

In July, two new asylum rules were issued: the “Safe 3rd Country” rule would require families seeking asylum at the southern border to first apply for asylum in Mexico or Guatemala and wait there; the other rule would make it more difficult for families to seek asylum on the basis of threats to family members’ lives. These rules would severely curtail legitimate asylum applications and have so far been blocked by the courts. Furthermore, Immigration and Customs Enforcement raids now lead to deportation of parents who have lived and worked here for many years and have U.S.-citizen children, rather than focusing on criminals and very recent arrivals, as previous administrations have done. Each week there seems to be another government action that disadvantages immigrants, such as a recent attempt to deport immigrants who are here legally to receive lifesaving medical treatments. These moves aim to strike fear into immigrants’ hearts, creating a state of siege.

How did we get here as a nation, as a people? In fact, we have a long history of anti-immigrant sentiment and action. Starting in the mid-19th century, anti-immigrant animus was widespread and directed first against the Irish and Germans. Although our most toxic racist legacy affects African Americans and Native Americans, Chinese people were excluded from immigration by law in 1882 and were not allowed to become citizens until 1943. Japanese naturalized citizens and American-born people of Japanese descent were interned in prisonlike environments during World War II. This racist and eugenics-based anti-immigrant fervor also affected what we now call white ethnic groups. Fear of Italians, Jews, and others led to severe restrictions on immigration from anywhere other than northern Europe from the early 1920s through the mid-1960s.4 Among other consequences, this policy led to the deaths of many Jews who could not escape from the Nazi killing machine because of U.S. immigration quotas.

Anti-Mexican sentiment dates back at least to the Mexican–American War of the 1840s and subsequent American westward expansion. Mexicans were viewed as “savages” and “mongrels,” “degraded” and “uncivilized.”4 From 1929 to 1936, our country perpetrated unconstitutional raids and deportations to Mexico that altered the lives of nearly 2 million people with Mexican-sounding names. Sixty percent of deportees were U.S. citizens, and many were born here.5 In 1954, “Operation Wetback” used military-style tactics to remove approximately 1 million Mexican immigrants, some of them U.S. citizens, from the United States. In 1996, as part of welfare reform, legally present immigrants, most of them Latino, were prohibited from receiving federal safety-net benefits for at least 5 years after their arrival.

Although we’ve long told ourselves that America welcomes immigrants with open arms, anti-immigrant sentiment is as American as apple pie and is baked into our history. What we’re witnessing today, though shocking, builds on a legacy that still haunts us. But U.S. physicians can stand up to the demonization and bullying; support, counsel, and nurture resilience in our Latino patients; and advocate for the basic human rights of all immigrants.