Rania Awaad

Opinion contributor

Two days after President Donald Trump announced a rule last August that made immigrants ineligible for residency and citizenship if they relied on government benefits, a 28-year-old Iranian asylum seeker died by suicide. His county-based social worker in Northern California later told me that Rouzbeh, who went by Adam, had confided in her that his suicidal thoughts stemmed from this new "public charge" rule. Despite reassurance from his family and social worker, he said it made him feel unsafe.

Adam, whose last name is being withheld for privacy reasons, believed that he would likely be extradited back to Iran on account of accessing public mental health services for his depression, not speaking English well and accumulating a large debt from an emergency hospital visit — all examples listed in the new rule as potential reasons to deny immigrants American citizenship. Complicating matters, extradition would mean a one-way trip back to the very conditions Adam was trying to escape by seeking asylum. Iran is one of the 13 countries listed in Trump’s now expanded travel ban.

As it turns out, refugees and asylum seekers are exempt from the expanded “public charge” rule. Adam's unfortunate misinterpretation highlights the confusion surrounding this new policy. And he wasn't the only one. As I was helping plan a community healing event after Adam's death, two other families reached out to our team. That was how we discovered there were three suicides by a refugee or asylum seeker from the same county following Trump's public charge announcement.

Three suicides is a warning sign

When two or more suicides take place in close proximity and time, there is heightened concern that a suicide cluster has formed and will spread. What has happened here in Northern California should be a caution to the rest of the country about the potential effect of national policies on the most vulnerable immigrant populations in the United States.

The “public charge” rule declares that immigrants who use public benefits, including cash welfare, food stamps, housing aid, Medicaid, or public mental health services, are considered dependent on government assistance and thus deemed “public charge.” The rule also says legal immigrants classified as public charge will become inadmissible for American citizenship and prevented from obtaining a green card.

This policy was scheduled to take effect in October 2019, but district judges in five states issued injunctions attempting to block it. The goal of the injunctions was to stem both the expansion of the types of public benefits that would constitute grounds for inadmissibility and the increased discretion proposed for immigration officers to determine if an immigrant is “likely” to become public charge. On Jan. 27, 2020, however, the Supreme Court lifted the injunctions in a 5-4 vote. The "Final Rule" took effect last month.

The Trump administration states that its goal for this policy is to encourage “self-sufficiency.” The reality, however, is that even short-term use of public benefits could result in disastrous consequences for immigrants. The likelihood of being classified as a public charge is increased for individuals with persistent medical conditions, less education, limited English proficiency, lower income and unsteady employment. Therefore, this policy targets the most vulnerable immigrants and implicitly discourages immigration by denying immigrants the most basic services necessary to live a physically and mentally healthy life.

'Public charge':Trump's immigration policy would have turned my great-grandfather away

Arriving on the heels of other policies that have negatively affected the mental health of immigrants, such as the travel ban, the public charge rule has led to widespread fear of deportation among immigrants, refugees and asylum seekers resulting in considerable psychological distress, and for some, a decline in mental health and safety as exemplified by the aforementioned cases. Furthermore, refugees and asylum seekers are often exposed to traumatic experiences before arriving in the United States. Untreated trauma is often compounded in the resettlement and acculturation process. It is therefore imperative that this vulnerable population be encouraged, not deterred, to access mental health services.

Fear of health care and food aid

The chilling effect of the new policy is that even those who are exempt from its application have started disenrolling from Medicaid and food benefits due to fear, language barriers, and a lack of clarity regarding the policy’s stipulations. One study found that disenrollment in health services by immigrants would amount to a difference of 538,000 fewer clients in a year. The administration last week announced that testing and treatment for Coronavirus Disease 2019 (COVID-19) would not count against "aliens" in a future public charge analysis. But how many will get that message? How many will take the risk of seeking care?

Fight or flight:For undocumented immigrants, our enforcement policies drive a public mental health crisis

With a Gross Domestic Product of $21 trillion, the largest in the world, the United States accepts fewer immigrants, refugees and asylum seekers, and offers these populations fewer public services as compared to less resourced countries. There is an implicit assumption that the cost in public benefits is not worth the contributions immigrants make to the nation’s economy. However, the literature indicates that between the years of 2005 and 2014 refugees and asylum seekers contributed $63 billion more to government revenues than they used in public services.

The Trump administration should increase awareness and clarity of services available to refugees and asylum seekers, and encourage them to seek proper health care. That would improve their physical and mental well-being and increase their economic contributions. It would also reduce the chances of a mental health crisis among vulnerable people who came to this country seeking safety.

Dr. Rania Awaad, co-editor of "Islamophobia and Psychiatry," is a clinical associate professor of psychiatry and director of the Stanford Muslim Mental Health Lab at the Stanford University School of Medicine. Follow her on Twitter: @DrRaniaAwaad. If you have thoughts of suicide, get free confidential help anytime at the National Suicide Prevention Lifeline, 1-800-273-8255.