Under the watchful eye of a volunteer, a toddler and her 6-year-old sister giggle in a hallway, delighted to be playing with a donated Barbie and baby doll. In a nearby room, their mother sits with a group of seven Latina teenagers and young women, crafting valentines out of pink paper and heart-shaped doilies. Across the hallway, nine teenage boys prep ingredients for arepas in a communal kitchen while a community chef gives instructions in Spanish.

The night’s activities are designed for 15- to 25-year-old survivors of human trafficking who traveled from their home countries in Latin America to seek refuge in the United States. It’s not uncommon for human smugglers, who are hired to help immigrants get across the southern border, to exploit vulnerable young people by forcing them into sex work or physical labor during their journey. Some of these survivors end up in Maryland and don’t know where to turn for health care, psychological support, employment and other essential services.

Asylee Women Enterprise (AWE), a nonprofit in northeast Baltimore, has partnered with HEAL Refugee Health & Asylum Collaborative, a Johns Hopkins-based partnership that assists people forcibly displaced from their home countries, to help trafficking survivors get the support they need. Together, they offer free individual therapy, host peer support groups, and connect youth to social, academic, employment and skill-building opportunities. The program, called Steps to Success, is one of many ways that Johns Hopkins and its pediatric faculty members are supporting immigrants and their children, who too often fall through the cracks of health care systems.

“The peer support groups were the first time that I could unravel what I had been through and talk to other people who had experienced the same things,” shares Juan (not his real name), an 18-year-old high school student and trafficking survivor from Honduras, speaking through an interpreter, who participates in Steps to Success.

In 2022, he made a perilous two-month journey to the United States with his 8-year-old brother. He’s still waiting to start the asylum process to see whether he will be allowed to remain in the country.

Meeting the needs of Juan and others like him is critical, says pediatrician Keith Martin, an expert on immigrant child trauma and resilience. “The goal of the Children’s Center and Hopkins is to achieve health equity among the kids of Baltimore City and surrounding areas. Immigrant kids are an integral part of that and cannot be ignored,” says Martin. He notes that low rates of health insurance coverage, language barriers, lack of transportation and prohibitive work schedules are common obstacles that can prevent immigrants and their children from accessing health care and social services.

Martin’s research is focused on how these and other barriers contribute to health disparities for Latinx children — an area for which limited data exists — and what can be done to level the playing field. The bulk of existing research pertains to U.S.-born children whose parents immigrated from Latin America, who are more likely than their peers to have mental health issues, utilize mental health services less than white children, and are more likely to be obese as compared to white children.

One of Martin’s goals is to identify a set of best practices when treating Latinx children in immigrant families, especially when it comes to addressing trauma. His research has found that racial bullying, discrimination from teachers, and deportation of family members are common stressors for Latinx children, yet these factors aren’t currently measured during screenings for adverse childhood experiences — potentially traumatic events found to have negative, lasting effects on health and well-being.

“Oftentimes, we see patients whose parents have been deported multiple times,” says Martin. “It is common enough that in our clinic at Yard 56, we have template letters that we send to immigration. In these letters, we try to articulate the medical problems of these kids and the harm that will come to them if you forcibly take away their parent.”

When Johns Hopkins pediatricians recommend specialized mental health services for their patients, they often hit roadblocks trying to connect children in immigrant families to care. Despite federal law requiring that children have access to free language services for mental health care, some providers still refuse to accept Spanish-speaking families. In one documented case, a 16-year-old Johns Hopkins patient was referred for a special type of behavioral therapy to treat anorexia, only to be turned away because her primary language was Spanish. In another case, a 15-year-old Johns Hopkins patient diagnosed with depression was denied treatment by a mental health agency because her mother could not speak English.

"We have many situations where a child has a complicated medical need, and figuring out a way to get them access to the resource they need is very challenging,” says Martin. Even when language is not an issue, parents’ inability to take time off work or find transportation to appointments can delay necessary medical treatment. “One of my teenage patients, for example, had a painful, benign tumor around his kneecap that needed to be removed, but he had multiple challenges in accessing care — like having to work and care for his family — that kept preventing him from going to see an orthopaedic surgeon,” Martin says.

By determining the right questions to ask during pediatric appointments, Martin’s research could one day help clinicians to better identify and treat the unique needs of children in immigrant families, as well as guide them to bilingual, trauma-informed resources within their communities. “If we can deliver more equitable care to Baltimore’s growing Latinx population, we can generalize it to deliver equitable care to everyone — that is really the goal,” he says.

‘If I Made It Here, They Can Make It Too’

When Monica Guerrero Vazquez was 10 years old, her parents left her in Ecuador. They were building a new life for the family in Spain, but it would be at least a year until they were ready for their three children to join them.

Before he left, her father sat her on his lap and taught her how to write her signature. “You are going to be in charge, so you have to learn how to sign,” he told her.

“I didn't know what was going on,” remembers Guerrero Vazquez, whose youngest sibling was still in diapers at the time. “I didn't know what life would be like for us or if I would even see my parents again. Many of my friends’ parents left, and they never came back.”

Without a responsible adult to help care for her brother and sister, she was forced to drop out of school and become a full-time caregiver. She looks back on that year as one of the darkest periods of her life. 

Three decades later, Guerrero Vazquez has two master’s degrees — one in computer science and one in public health — and is working toward a doctorate in public health at Johns Hopkins. She also serves as executive director of Center for Salud/Health and Opportunities for Latinos (Centro SOL), an academic-community partnership at the Johns Hopkins University School of Medicine based at Johns Hopkins Bayview Medical Center that is working to improve health and opportunity for the Latinx community in the Baltimore area.

Centro SOL, which is celebrating its 10-year anniversary this spring, connects people to medical resources and social services, offers online and in-person support groups, and hosts workshops on topics like teen suicide prevention and mindfulness. The center’s faculty members, most of whom have appointments in the Johns Hopkins University School of Medicine, also conduct research on the unique health issues affecting Latinx children and adults in Baltimore.

“We sit at the crossroads of research and community outreach,” says Guerrero Vazquez, whose research focuses on suicide prevention among non-English-speaking youth. According to 2019 data from the Centers for Disease Control and Prevention (CDC), Hispanic adolescents are more likely to die by suicide than their non-Hispanic white counterparts, and suicide attempts were 30% higher for Hispanic high school girls.

Guerrero Vazquez says many of the girls she works with through Centro SOL have no time for extracurricular activities or socializing with friends because they are consumed with responsibilities at home. “They are going through very hard situations sometimes,” explains Guerrero Vazquez. “If you’re the oldest daughter, you’re going to be in charge because your parents are going to be working. You have to be taking care of everything.”

Last year, Guerrero Vazquez launched a mental health pilot project for Spanish-speaking students at Benjamin Franklin High School, in southern Baltimore, which has since received funding from the Bloomberg American Health Initiative. As part of the pilot, 25 immigrant teenagers attended group meetings, where they were encouraged to open up to Guerrero Vazquez and their peers.

“It’s important because these young people don’t have access to mental health care, and they don’t have a safe space where they can go and talk about their thoughts and feelings,” says Guerrero Vazquez. Most of the students she works with are still going through the resettlement process and facing challenges related to their immigration status, which can affect their ability to get a part-time job or receive financial aid for college. Many are also struggling to reconnect with formerly estranged parents, complete coursework in a new language and manage the stress of household responsibilities. 

“I took my siblings to school. I picked them up. I helped them with homework. And I see the high schoolers in our youth program doing the same thing because their parents are working,” says Guerrero Vazquez. “To help build their self-confidence, I tell them that, if I made it here, they can make it too.”

 A Lifeline for Asylum Seekers

While Centro SOL focuses exclusively on the well-being of Baltimore’s Latinx community, HEAL serves asylum seekers and refugees from around the world, many of whom have experienced severe trauma. HEAL co-founder and medical director C. Nicholas Cuneo, who began working with refugees in Baltimore more than a decade ago while a student at the school of medicine, has heard stories of kidnapping, rape, government-sponsored torture and people being dragged through the streets solely because of their sexual or gender identity.

“Thankfully, the United States still has a reputation as a country of hope, of safety, of opportunity — and that’s attracting people to our doorstep,” says Cuneo, a pediatrician at the Johns Hopkins Children’s Center, whose research explores patterns of trauma and violence among asylum seekers, as well as political determinants of health, such as immigration enforcement policies.

According to the latest census data, the number of immigrants to the U.S. grew to the highest level in two decades last year. Today, immigrants make up nearly 16% of Maryland’s population, compared to less than 10% in 2000.

HEAL is a partnership between Johns Hopkins, the Esperanza Center, AWE and Loyola University Maryland. The Esperanza Center, a Catholic Charities of Baltimore program, is a nonprofit that connects immigrants to job training, employment, English classes, housing and free health care should they not qualify for government assistance due to their immigration status.

HEAL has grown significantly over the past two years. Initially home to Maryland’s first and only comprehensive asylum clinic, HEAL has since expanded to provide comprehensive primary care services to immigrant survivors of torture at the Esperanza Center, as well as a range of mental health services to asylum seekers and youth survivors of trafficking, including Juan. He participates in the Steps to Success trafficking survivors program run by HEAL and AWE, which has been funded by grants from the U.S. Department of Justice as well as Baltimore’s Promise and the Annie E. Casey Foundation.

“Steps to Success helped me process my past and deepen the way I can talk about what I’ve been through. I have more empathy,” says Juan, who comes in regularly for music therapy, stress reduction workshops and cooking classes. He recently decided to join Steps to Success’ Youth Advisory Board. “Because of the life experience that I’ve had, I find that I’m more mature, and I want to support and help other young people like me.”

Creating a partnership to help asylum seekers like Juan was at the top of Cuneo’s to-do list when he joined Johns Hopkins’ pediatrics and medicine faculty in 2020. He launched HEAL in November 2021 with co-founder Nouf Bazaz, a clinical assistant professor of counseling at Loyola University Maryland and expert on refugee mental health.

Last year, HEAL provided services to 207 unique clients from 36 countries of origin, and about one-third were children or young adults. The children referred to HEAL commonly struggle with trauma-related mental health conditions, such as anxiety, depression or PTSD, as well as delayed or misdiagnosed developmental disabilities, like autism.

“There is such a dearth of resources for quality counseling that’s accessible to kids. If we can help to fill that niche, that would just be huge,” says Bazaz, who serves as HEAL’s mental health director. Sixty-seven immigrants received mental health services through HEAL in 2023, including 12 who received individual therapy from Bazaz.

She often meets with her youngest clients in a therapy playroom at AWE, which is stocked with art supplies, puppets and stuffed toys with sewn-on faces representing different emotions — objects that make it easier for children to reenact experiences and communicate their feelings. Bazaz’s favorite tool in the playroom is a sand tray, where kids use figurines to create scenes in the sand.

“Kids are able to create these worlds that can be quite symbolic of their own,” she says. “One kid is obsessed with creating disaster scenes in the sand, and together we have to save all the people in often elaborate ways. So, it does get a lot out.”

Building a Case for Asylum

One of the most important services that HEAL offers is free forensic evaluations — an hourslong process that can include a physical exam and psychological assessment to document any abuses that a client may have experienced in their home country — and they can make or break an immigrant’s case for receiving asylum in the U.S.

“Applicants’ chances of being awarded some sort of humanitarian protection, including asylum, can approximately double if they submit a detailed medicolegal evaluation,” says Cuneo. “In one recent study, 81.6% of cases where a forensic medical evaluation was submitted were granted protection, compared to the national rate of 42.4%.”

Over the last two years, HEAL has grown into one of the highest-volume forensic evaluation clinics in the country, and it’s one of the only clinics in the region to offer the service at no cost. Such evaluations can be more than $2,000 on the private market, and HEAL’s patients often travel from surrounding states for the service.

Occasionally, HEAL’s forensic examinations will confirm a case of female genital mutilation/cutting (FGM/C) — a traditional practice in some communities in Africa, the Middle East and Asia, which involves partial or total removal of the external female genitalia for nonmedical reasons. Survivors of the procedure may experience long-term medical issues, such as pain during menstruation and intercourse, keloids, neuromas, complications during childbirth and constant irritation that makes everyday activities — like riding a bicycle — unbearable.

The World Health Organization estimates that more than 200 million girls and women alive today have undergone FGM/C, and most of them received the procedure under the age of 15. The U.S. is now home to as many as half a million girls and women who have undergone FGM/C in the past or may be at risk for undergoing FGM/C in the future, according to the CDC. HEAL sees an average of about seven cases per year.

“The CDC is coming out with new data about the gaps in care experienced by women and girls with FGC in the United States,” says Nicole Warren, HEAL’s associate director of women’s health and an associate professor and midwife at the Johns Hopkins University School of Nursing. Warren is an international expert on the subject of FGM/C, which has been the focus of her research career. “When we talk about FGC, there’s the harm of the initial cut, but there’s also harm that comes from not being able to access appropriate care. Most nurses, doctors and midwives are completely unprepared.”

To fill this health care gap, HEAL has built a trauma-informed team of experts in sex therapy, pelvic floor physical therapy, urogynecology, nursing and midwifery. These specialists reflect the evidence that women impacted by FGM/C should be offered holistic health services, says Warren.

“It’s such an innovative, supportive space. The multidisciplinary services available at HEAL are extremely difficult to find, and it didn’t exist at all in the Northeast,” says Warren. “I've been at Hopkins for 15 years, and this is the most rigorous, compassionate, committed and productive team I’ve ever been part of. They're getting stuff done, and it's a really exciting place to be right now.”

HEAL’s work is made possible with the help of over 100 volunteers, including many Johns Hopkins students and residents, along with a patchwork of government and philanthropic funds. HEAL has received grants from the U.S. Office of Refugee Resettlement Services for Survivors of Torture Program, the U.S. Department of Justice Office for Victims of Crime, the Aaron Straus and Lillie Straus Foundation, the Abell Foundation, the Goldseker Foundation, the Leonard & Helen R. Stulman Charitable Foundation, and the Center for the Study of Democratic Institutions. Johns Hopkins provides in-person interpretation for HEAL and funding for transportation assistance for clients facing significant barriers. Johns Hopkins’ Urban Health Institute has also funded HEAL’s student arm at the school of medicine, the Refugee Health Partnership.

“To do this work is very hard. It’s so difficult to assemble these coalitions,” explains Cuneo. “But once you have the right mix, it’s beautiful.”

Meeting the health care needs of immigrants comes with challenges, but Johns Hopkins doctors and staff members say the resilience of their clients never fails to inspire them. Guerrero Vazquez has seen students blossom during their time at Centro SOL, with some going on to receive full scholarships at Loyola University, Goucher College and Johns Hopkins.

“Being undocumented and being able to get into Johns Hopkins is a huge deal,” says Guerrero Vazquez. “One girl who attended our mentoring and summer programs was very lost and didn’t know what she wanted to do. She later told me, ‘Thanks to your help, I went to nursing school.’ She graduated last December.”

When given the opportunity to fulfill their potential, immigrants can successfully rebuild their lives, even after suffering unspeakable things, says Cuneo.

“I’ve seen folks who start with very serious challenges because of the traumas they’ve experienced blossom over the course of months into completely different versions of themselves. They just needed the chance to thrive and the security to establish their lives,” he says. “That’s what makes the work worth it.”