Imagine you’re an employee in the Boston Medical Center Emergency Department and a new patient appears in the board with a chief complaint of homelessness. With the help of a Haitian Creole interpreter, you go into the room and hear their story.
The mother reports that her 2-year-old daughter is constipated but healthy overall, and she gives you a vaccination card from Brazil showing she is up to date with all her immunizations. She and her child initially arrived in Boston from Haiti via Brazil seven months ago. Most recently, they have been staying at a residence for which they had paid rent in advance. However, they had no official lease. Last night, the mother was assaulted by the landlords, told to leave, and arrested by the police. She spent the night in jail, was held under the wrong name, and wasn’t provided any language assistance. The mother was released this morning, and she and her daughter are now presenting to the emergency room in search of housing because she did not know where else to go.
How did this mother and daughter end up in this position, seeking housing via the emergency department? To understand that, you must look at the geopolitical context of Haitian migration and complex border and housing issues they face when they arrive here.
How we got here: A very brief history of Haiti
Poverty in Haiti did not happen by accident. The combination of political instability, civil unrest, and recurrent natural disasters have stunted Haiti’s economic growth. Haiti is a strong, vibrant country and stands proudly as the first independent nation free from slavery, but it has a long history of colonial subjugation and political turmoil. In 1804, the Haitian Revolution succeeded in expelling French colonizers and establishing Haiti as the first country to abolish slavery and emerge as a free independent Black nation.
Haiti stood as a beacon of hope and independence, but it paid a large price for this freedom. France extorted an enormous amount of money from Haiti, forcing it to take a loan from the French, creating what is now commonly referred to as Haiti’s double debt. Many economists believe that had Haiti not been extorted by France, Haiti’s economy would have been able to grow to be the equivalent of about 115 billion U.S. dollars today. Now, Haiti currently has the lowest GDP per capita in the Western hemisphere.
In the 20th century, as U.S. business interests increased in Haiti, leaders of these businesses worked in concert with the U.S. government to destabilize the Haitian government, setting the stage for a U.S. invasion in 1915. After U.S. military withdrawal in 1934, political unrest continued, and Haiti entered into the Duvalier family dictatorship — an era marked by corruption, violence, and repression. Movement toward a democratic government progressed in subsequent presidential cycles, but years of political coups, corruptions, natural disasters, and the worsening economy culminated in the assassination of Haiti’s most recent president, Jovenel Moïse in 2021.
The rise of Haitian immigration to the U.S.
On January 12th, 2010, a devastating 7.0 earthquake struck near Haiti’s capital, Port-au-Prince. More than 220,000 people died, and around 300,000 people were injured. The city’s infrastructure collapsed into rubble, leaving the city almost uninhabitable. This natural disaster became a major catalyst for emigration from Haiti to the U.S.
Haitian nationals were granted temporary protected status (TPS), allowing for those impacted by the disaster to lawfully live in the U.S. for a limited time. Those with TPS can obtain work authorization to legally work in the U.S. but cannot apply for citizenship like refugees or asylees. TPS has been historically tenuous in the U.S. immigration system. There have been several efforts to repeal TPS for Haiti, however it is currently extended until 2023.
“With this context and the additional challenges of language barriers, it’s no surprise the Emergency Department is often a destination of last resort to safely access the EA shelter system.”
Migrating to the U.S. from Haiti amplified again after Hurricane Matthew in 2016 and another 7.2 magnitude earthquake in 2021. These factors, coupled with the president’s assassination, caused many Haitians to move north toward the U.S. in search of a welcoming haven.
However, the journey to North America is extremely treacherous, taking weeks to months and mostly traversed by foot. One of the most dangerous parts of this journey is the crossing of the Darien Gap, a large stretch of jungle and mountainous rainforest between Colombia and Panama, with major sections controlled by paramilitary groups and gangs. Some people do not survive this arduous trek, and for those who do make it through the several-thousand-mile journey, entering the U.S.-Mexico border is another challenge.
Haitian migrant obstacles at the U.S.-Mexico border
Upon reaching the U.S.-Mexico border, many migrants await processing and encampments with minimal support, hoping for a chance to present to Border Patrol and to be granted legal entry into the U.S. However, at the onset of the COVID-19 pandemic, under the Trump administration, the U.S. government invoked Title 42 of the U.S. Code of Laws, which denied entry to migrants, “in order to prevent spread of communicable disease.” This allowed for the swift expulsion of many migrants from the U.S.-Mexico border and denied them the right to seek asylum.
By early 2021, after Biden took office, the proportion of Haitian migrants allowed in started increasing, at least partially due to instruction from the Biden administration allowing humanitarian exceptions to Title 42.
While migrants now have a greater chance of establishing residence in the U.S., it is far from a perfect system, and migrants are often kept in inhumane detention centers facing unsafe sanitary conditions with limited access to food and water, in addition to reports of racist and dehumanizing treatment at the border in detainment camps. Haitian migrants are also flown on expulsion flights back to Haiti once they reach the border, a practice that accelerated at the start of the pandemic and continues today.
Arrival: Housing barriers in Massachusetts for Haitian asylum-seekers
There exists a combination of barriers to obtaining non-shelter housing, including Boston’s expensive rent, work restrictions for migrant families, and difficulties inherent in relying on family and friends for a place to stay.
In Massachusetts, the family homelessness system is called the Emergency Assistance (EA) program, and it is operated by the Department of Housing and Community Development (DHCD). This program provides crucial shelter and rehousing services to families with expectant mothers or children experiencing homelessness, including many migrant families. Massachusetts is the only state with a right to shelter law. This mandate requires the state to provide temporary emergency shelter to every person who is eligible for services every night.
Many migrant families may also be eligible for EA shelter — however, they must provide extensive documentation as part of the application. Initial documentation requirements include identification for all adults and all children, proof of the relationship between family members, proof of child custody, and proof of residence in Massachusetts. If these initial documentation requirements are met, DHCD must place eligible applicants in a temporary shelter immediately for up to 30 days. This process is called presumptive placement. This proof of documentation is often the first of many barriers, as migrants have traveled thousands of miles through many countries sometimes over the span of years.
After a family receives presumptive placement in a temporary shelter, they have 30 days to produce another round of required documentation to qualify as being fully eligible for EA shelter. Three major categories of documentation are required: the reason for homelessness, the legal status of at least one family member, and proof of income or recently ended employment.
For migrant families who have applied for asylum, which is the case for many Haitian families we see here at BMC, one of the most notable barriers to housing is that newly arrived families also face work restrictions, which limits their means of legal income — the final element of that list of documentation.
After a complete asylum application has been received by the U.S. Citizenship and Immigration Services, applicants cannot receive an employment authorization document (EAD) until the application has been pending for at least 180 days. In other words: Asylum-seeking migrants are barred from working for at least six months after their arrival. This is a significant barrier to finding a means for income and the ability to afford housing.
“Asylum-seeking migrants are barred from working for at least six months after their arrival. This is a significant barrier to finding a means for income and the ability to afford housing.”
In addition, there are many logistical barriers to shelter access. For example, the state shelter system has a limited hours for intake, it’s open only on weekdays, and it has a complicated application process.
With this context and the additional challenges of language barriers, it’s no surprise the Emergency Department is often a destination of last resort to safely access the EA shelter system.
It bears out in BMC’s own data. In 2022, 80% of families experiencing homelessness in the pediatric ED at BMC were Haitian asylum-seekers, and 42% of the total presenting families, which includes Haitian families as well as others, presented to BMC within 30 days of arriving to the U.S.
Let’s go back to the story of the mother and her 2-year-old girl, who immigrated to Boston from Haiti by way of Brazil and presented to the BMC ED in search of housing. Why would they come to the ED for housing?
In short, families present to the ED because they have nowhere else to go.
This story was adapted from a presentation by the Health Equity Rounds team. Health Equity Rounds is a solutions-oriented, case-based interdisciplinary grand rounds conference series focused on confronting the effects of racism and other systems of oppression on health and healthcare. This conference series began in the Boston Medical Center Department of Pediatrics in 2016, and since then, we have mentored dozens of other institutions to start their own programs.
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