was originally reported by Barbara Rodriguez of .

Dr. Lara Jones still remembers her visceral reaction to the image of Liam Ramos. It wasn’t the most famous one, of with ICE officers behind him. It was one from days later, of Liam while both were in custody in Texas.

“He looked pale, he looked sickly. He looked like a completely different child,” she said. “When I saw that image, my doctor brain turned on. I was like, this kid is sick. He needs medical attention.”

Jones, who is double board-certified in pediatrics and pediatric critical care medicine, can quickly assess a lot based on a child’s appearance.

“I can tell in the first 10 seconds that I look at you from the door, before I even put my hands on you, before I put a stethoscope on your chest — I can look at you, and I can know right away, you are going to be fine, or you are really sick and you need attention,” she added. “He looked very sick.”

Jones couldn’t sleep that night. Liam’s well-being consumed her while at work the next day at a California hospital. After a round of patient visits, she went into a private room and “broke down and cried.” She needed to do something.

Since then, Jones has become part of — all pediatricians, all mothers — in immigration detention out of concern for their health. They warn that the detention of these children is causing severe and lasting harm to their mental and physical health, and say that of kids allegedly facing delayed and inadequate medical care under DHS demands urgency and transparency.

“We are traumatizing children, and we are putting them in dangerous environments,” Jones said.

These doctors are in detention, to help families in need of emergency assistance and to demand accountability so that children who remain in custody receive evidence-based standards of care.

“We are mothers of young children, and we are doing all of this in between shifts, after working night shifts, during nap time,” Jones said. “We are just doing as much as we can, in the time that we have, while we are working full time and being full-time moms.”

Just weeks ago, Jones and the other women — Dr. Ashley Marie Cozzo of Connecticut and Dr. Anita K. Patel of Washington, D.C. — did not know each other personally. Now they’re in contact daily through a group text that pings at all hours of the day. They use the chat to think through advocacy ideas, to troubleshoot potential challenges and to align their priorities.

“We’re trying to figure out every day in our brainstorming, ‘What’s next? What’s next?’” said Cozzo, who is double board-certified in pediatrics and neonatal-perinatal medicine. “I love a group project, and this is such a unique situation.”

Patel, who is double board-certified in pediatrics and pediatric critical care medicine, said the quick camaraderie among the women has “reinvigorated” her after years of online campaigns around unrelated advocacy issues.

“You have three critical care doctors for kids, and there are certain qualities inherent in pediatric critical care specialists — we will not stop until we have either saved a kid or we know that there is no chance of saving them,” she said. “We all have that personality, because literally that’s what we do in our jobs.”

Liam’s story propelled their cause. As the image of Liam seemingly in a lethargic state ricocheted across the internet, the women shared their outrage with medical peers. Jones and Cozzo circulated a small online petition calling for Liam to be returned home, and amid the national outcry, . (The Ecuadorian family has an active asylum case, and it’s unclear for now whether they will be able to permanently stay in the United States.)

The doctors then connected with Patel, and the three agreed to work together to bring more awareness to other children in detention. Patel said the power of imagery catapulted Liam’s story.

“If he was an older kid, or even if he was Liam without the bunny hat — the outcry may not have come,” Patel said. “And all I could think was Liam deserved that outcry, and every single kid in detention needs that outcry.”

The trio has fixated on the Dilley Immigration Processing Center, the facility near San Antonio that houses families, in part because they are in frequent communication with a journalist, Lidia Terrazas, on people impacted by detention.

When Terrazas highlighted in early February the story of a 2-month-old baby named Juan Nicolás, the case crystallized the doctors’ urgency. The boy had been in respiratory distress while at Dilley, but had allegedly received delayed care as his condition worsened. He was sent by ambulance to a hospital on February 16, according to Patel, after an unresponsive episode where detention officials could not wake him. DHS later deported the baby, his mother and other family members, including a 16-month-old, to Mexico.

Jones was able to connect by text with Mireya López Sánchez, Juan Nicolás’ mother. The postpartum mother said that her milk had dried up while at Dilley. Patel is still nursing her toddler; the parallels — the universal urge a mother has to feed her baby — linger for her.

When Patel nurses her own child, “I think of Mireya, whose milk dried up because she was so stressed and nutritionally deficient that she couldn’t breastfeed, and then when she couldn’t breastfeed, then she couldn’t afford clean water that wasn’t brown or smelled like chlorine to make formula.”

, which has partnered with the doctors to raise money for commissary funds, detainees at Dilley have to spend $40 to buy a four-pack of large water bottles and $35 for a 12-pack of small water bottles.

A spokesperson for DHS did not respond to a request for comment from The 19th, but the agency of malnourished or mistreated children and claims people in detention have access to medical care and adequate food. Emergency crews were called to the facility at least 11 times since September for children with symptoms including bronchitis, respiratory distress and fever, .

CoreCivic, a private company that runs the Dilley facility, deferred questions to DHS but that claims of inadequate medical care are inaccurate and “directly contradicted by the comprehensive, around-the-clock care delivered by our licensed physicians, dentists, advanced practice providers, nurses and mental health professionals.”

Jones doesn’t buy that when it comes to Juan Nicolás, whose mother reportedly told officials that her newborn was having difficulty breathing and was vomiting. Mireya said that instead of being seen by a medical professional, guards at the facility monitored the newborn for two days before he was sent to the hospital in distress.

“I don’t know what they were assessing, but they’re not assessing it through the lens of a pediatric expert,” Jones said. “They’re not doing the appropriate medical workup. So that case alone is proof of delayed care and denied appropriate care, because the appropriate care for a 2-month-old with difficulty breathing and vomiting is to go to the emergency department.”

Cozzo noted that several children died in 2018 and 2019 while in immigration , or . In 2023, — reportedly after her mother repeatedly sought medical care for her.

“We have a precedent of the highest degree of loss: children’s lives,” Cozzo said. “It has happened before, the things that these women are worried about — it’s only going to be a matter of time before we don’t learn from the mistakes of the past and another child dies.”

As the doctors circulated Juan Nicolás’ story online, they connected to help . They also helped secure a hotel room for Juan Nicolás’s family amid their deportation to Mexico. They are now raising money . As they hear of specific cases, including those of and , they try to spring into action by either raising public awareness or funds.

The medical community has long expressed alarm about how children’s health can deteriorate in immigration detention. concluded that children’s mental health suffers and there’s a cascade of ripple effects, including anxiety disorders, depression and developmental regression and delays. The issue has been examined , with similar outcomes.

There are also standards of care for immigrant children in detention, and states that children should not be detained for more than 20 days. But that some children are being held in detention for much longer — weeks or months. The publication estimated at the time that at least 3,800 children under 18 had been booked into ICE since President Donald Trump, who campaigned on mass deportation, returned to office. More than 1,300 children were held last year for longer than 20 days.

The American Academy of Pediatrics (AAP) has its call for limited exposure of children in DHS facilities. Dr. Sural Shah is chair of AAP’s Council on Immigrant Child and Family Health. She said the council, which was very responsive during the first Trump administration’s family separation policy, has been accelerating its work in recent months.

“We’re always active, always sharing information. But the era that we’re in now — it’s been a heightened sense of need, of urgency, of hey, this is happening, and we need to do something about it,” she said. “We need to figure out how to band together, how to lift up voices, how to gather health care professionals and folks that care about children’s health to stop these practices because they’re so harmful to children.”

Shah added that she’s not surprised that pediatricians are leading organic advocacy efforts.

“It is something that is deeply woven into the fabric of who pediatricians are,” she said. “We have a deep understanding of the range of factors that affect children and their families.”

Over the past few weeks, the trio of doctors began drafting and circulating a letter, which was later signed by thousands of medical professionals, to be sent to DHS officials and several key senators with roles in immigration enforcement oversight. , dated February 26, alleges unsanitary detention conditions and inadequate access to food and clean water. It also expresses concerns of a measles outbreak within the Dilley facility. Infants are typically too young to be vaccinated against measles.

Kristi Noem’s ouster as head of DHS last Wednesday doesn’t alter the demand for accountability, said Cozzo.

“I actually don’t necessarily think that changing the face changes anything, because it’s just a complete system that is broken,” she said.

All three agreed that the letter is a start.

“This letter is day one of a marathon,” said Patel, who was a guest of Democratic Rep. Joaquin Castro at the recent State of the Union address, with the goal of elevating the issue. “The point of the letter was to clearly and succinctly as possible, dictate what has been documented as known medical negligence or medical harm or human rights violations.”

They want to grow public pressure while helping as many children and their families as possible. Jones said their advocacy is about the health and well-being of children. She doesn’t see that as political.

“This is an issue about child welfare,” she said. “I feel like if we can continue to stand our ground about the fact that we are causing preventable, measurable, well-studied, predictable harm to children that is not justified. There’s no context in which that is justified, and so I think we just have to continue to get that message across — to the public, to lawmakers. There will be challenges at every step of the way, no doubt, but I think the truth and what’s right is on our side.”

The former independent presidential candidate has a complicated past as a member of a famous Democratic political dynasty that includes his uncle, former President John F. Kennedy, and his father, U.S. Sen. Robert Kennedy, both assassinated in his youth. He struggled with addiction, and an arrest for heroin possession in the 1980s led him to volunteer with the Natural Resources Defense Council to fulfill community service hours, which jump-started his career in . 

Then, about two decades ago, Kennedy became interested in vaccine conspiracy theories, including the disproven link between vaccines and autism, which has become a focal point of much of his work since. He has peddled other , including that Wi-Fi causes cancer, that chemicals in water can lead to children becoming transgender and that AIDS may not be caused by HIV. In 2021, he was named one of the of misinformation about COVID vaccines on social media. 

Doctors and advocates have expressed alarm about the impact he could have on the department, while some have applauded his more mainstream views, such as a focus on preventative care through healthy eating and exercise and a commitment to removing processed foods from .

His beliefs and proposals are particularly relevant for kids, amid heated debates around school vaccination policies and a in the percentage of kindergarteners who have gotten state-required vaccinations.

If confirmed by the Senate, Kennedy would take control of an agency with one of largest federal budgets — — that employs about 90,000 people across 13 agencies, including , (the latter pays for a host of for eligible children), the and the

To better understand the pediatric and school-based health care implications of some of Kennedy’s proposals, The 74’s Amanda Geduld spoke with Leana Wen, an emergency physician and contributing opinions columnist for . The parent of two school-aged kids is also a professor of health policy and management at George Washington University, a non-resident senior fellow at the and Baltimore’s former health commissioner.

Geduld then spoke with medical legal expert Richard H. Hughes IV about how likely Kennedy’s confirmation is and what kind of power he would wield if confirmed. Hughes is a professor at George Washington University’s law school, where he teaches a course on vaccine law, and a partner at the firm . He formerly worked as the vice president of public policy at Moderna — one of the co-producers of the first FDA-approved COVID-19 vaccines — guiding the company’s policy strategy during the pandemic.

These interviews have been edited for length and clarity.

The medical perspective

The 74: Kennedy has a long record of promoting and even before the pandemic had built a following through his anti-vaccine nonprofit group, . 

In the past few weeks, he’s backed off these assertions a bit, but I’m still wondering what impact his rhetoric around vaccines could have— especially around parents vaccinating their kids. Can you also speak to some of the science behind vaccinating kids in the first place and what impact that’s had on pediatric health care?

Leana Wen: I think it’s important for us to start with the facts and to talk about what happened before there were vaccines for a variety of diseases. In the decades past, prior to vaccines, we used to see children succumbing to diseases that we now do not see anymore. We used to see children becoming paralyzed from polio and their parents being too scared for them to interact with others and go to school. We used to see children with severe, lifelong problems — including with their brains and other organs — because of measles, mumps and other diseases that we now consider to be eliminated thanks to vaccines. 

And so I think part of why vaccine misinformation has caught on is that the current generation of Americans have not experienced how terrifying these diseases have been that vaccines prevent. And I would really hate for us to see these diseases return before people recognize how much vaccines are life saving. 

I think it’s also important for us to mention the facts. It’s a fact that in 1900, 30% of all deaths in America occurred in kids under 5. Now that number is 1.4%. Back in 1900, the three leading causes of death were all infectious diseases. Now they aren’t. Thanks to antibiotics, thanks to sanitation, also thanks to vaccines. 

There was done recently that was published in the journal The Lancet. The study found that vaccines against the 14 most common pathogens saved 154 million lives globally over the past five decades, and that these vaccines cut infant mortality by 40%. 

And so it’s really heartbreaking to hear anyone spread misinformation about vaccines, but certainly it would be extremely concerning from a public health standpoint, if the individual in charge of science and health in this country is the one spreading such falsehoods. This could have a huge impact on trust in vaccines. And unfortunately, that could reduce vaccine uptake and lead to the return of these diseases that we thought were eliminated.

Kennedy has proposed removing processed foods from and limiting the use of food dyes, saying that the U.S. obesity epidemic, as well as a rise in chronic diseases like diabetes, are the result of He recently called out the nutrition department, which he says is Can you talk a little bit about what impact the food that we see showing up in school lunches has on kids, and what we know about food dyes?

I want to focus on ultra-processed food. We know that ultra-processed foods are associated with a whole variety of health problems — certainly things like diabetes, obesity, other chronic diseases like that — but also with depression and early dementia and potentially behavioral developmental issues in children as well. 

Unfortunately, some studies show that as much as 70% of the diet that Americans consume come from ultra-processed foods — that the calories from these diets come from ultra-processed food. I think it would be great if we can start reducing or removing ultra-processed food from school lunches. There has been some research done on food dyes and other additives. Reducing these in school lunches would also be a positive step.

He’s also mentioned that the same way that a doctor can prescribe Ozempic to treat obesity, they should also be able to prescribe, say, and have that covered by health insurance policies. I’m wondering what that might look like for kids as well, and what role pediatricians might play.

I don’t think any pediatrician would disagree with the idea that we have to focus more on prevention — that promoting healthy lifestyle, increasing exercise, improving diet, these would all be excellent for the promotion of health and well-being in our children. 

To be clear, it’s not these ideas that Kennedy is promoting that the medical profession would have an issue with. It’s that mixed in with many of these good ideas, are our concerns about misinformation around vaccines and that traditionally have not been considered to be safe and effective. 

After Kennedy’s nomination, he wrote on on Jan. 20, “The Trump White House will advise all U.S. water systems to remove fluoride from public water.” Can you talk a little bit about the role of fluoride in drinking water — specifically for kids.

This is an area where re-examination of the current policy would be a good idea, because this is a nuanced and complicated issue. On the one hand, we know that fluoridating the water supply has reduced cavities in children, but that effect was seen the most before widespread use of fluoride toothpaste.

We also know that fluoride in large quantities has toxic effects, including on bone development, on teeth discoloration and potentially on the developing brain if consumed by the pregnant woman. And so the question then is, what is the amount of fluid that would be optimal for promoting both dental health and reducing other effects? …

I think these are all reasonable questions to be asking — again, though, using science as the basis and not approaching this as an activist who already has a preconception in mind.

Are there any other policy ideas that Kennedy has put forward that you have thought of as either welcome news and an exciting change or particularly concerning?

None of what we’re talking about here is new. I think we can divide the proposals by Kennedy into three categories. One are things that are good ideas. For example, removing ultra-processed lunch or ultra processed food from school lunches. 

The second category are things that deserve a re-examination, and depending on what we find, may or may not be a good idea. That includes the fluoridation.

And then the third area would be things that have been proven to be wrong. For example, misinformation around vaccines.

And so again, I think to your point, none of these things that have been brought up in the category of good ideas is new, but that’s how I would think about this.

The legal perspective

The 74: Speaking about Kennedy at a rally recently, Trump said, How accurate is that? Can he really go wild on health? What are some of the congressional stopgaps there, and how much power does Kennedy actually have to enact these proposed policies? 

Richard H. Hughes: I think we could break that down into sort of two parts: Is Trump going to make good on that promise? and How far will RFK go? 

I would say that President Trump is very intent on making good on that promise. He went through with the selection of RFK. If you look at the appointments across the board, the nominees he selected are very unconventional. He’s very intent on disruption. 

And if you look at the health appointees in particular, there is some consistency there, right? They all hold really unconventional views. They come from very unconventional backgrounds for these types of roles. There are some questions about the adequacy of some of their experience and qualifications for these roles. There is also some consistency across the nominees that this sort of unconventional, non-mainstream views on COVID and the COVID response, as well as this focus around infections versus chronic disease. A lot of them have said we think we should be focused on chronic disease. A lot of them have espoused misinformation about vaccines. 

In terms of the legal authority, Congress has given a lot of really sweeping power to the secretary. When Congress gives the authority to the executive branch to do something, and it does it really clearly, the executive branch has a lot of leeway … 

So I’ll just give you an example. A lot of the questions I’m getting are about vaccine recommendations and vaccine requirements. There is the (ACIP). That is a committee that is created by the secretary… 

There are all of these requirements for programs or payers to provide coverage of the vaccines that are recommended by the committee. And so there are really interesting questions about, well, if he stopped convening the committee, if he eliminated the committee, what impact would that have?

There’s a potential trickle down effect, because a lot of states actually either look to that committee to determine what their [vaccine] policy should be, or they just refer to the committee and require, say, you know, for school entry, they require vaccination in accordance with the schedule that’s determined by the ACIP. 

That’s sort of a very specific area … 

At the FDA, there’s a lot of room for someone to come in, introduce subjective views on science, and say, “Well, what do we mean by safety? What do we mean by efficacy? Your traditional randomized, controlled trial, that doesn’t tell me what I need to know…” [That] might be the view of somebody at the agency in this administration, and they might try to introduce alternative evidence, and they would have some latitude to do that.

Just turning a little bit more to vaccines, it sounds like whoever is running this agency and convening this committee has a lot of power to potentially help determine what vaccines are going to be covered by health insurance. Is that correct?

That’s right. Congress requires payers to cover vaccines that are recommended by that committee. If those recommendations are rescinded by the secretary, which the secretary has the authority to do, that really throws a lot into question there. 

Now I’m having a really healthy, friendly debate with one of my mentors over the legal challenges that one could bring to challenge that sort of decision. There are some potential checks on this in the courts, but it’s all going to be really circumstantial.

Thinking specifically about schools, you mentioned that folks look to this committee to help determine what vaccines are required for students. Can you explain a little bit about how that works? How might RFK’s policies impact that?

If you’re interested — it’s open access — I just wrote in this month’s issue of Health Affairs on the relationship between ACIP recommendations and state school requirements … 

But, this is the authority of the states, and it’s really interesting in a Republican administration to think about the federalism debate … and you’re going to see this tension play out in this administration over the role of the states and the federal government. 

And it’s going to play out in the arena of public health and around vaccine policy … The federal government can come in and play a really important role when you have a threat that, say, goes across state lines. But states have to be able to enact these measures to protect themselves, to protect their people. 

The Jacobson v. Massachusetts case recognized that states can require immunization. [In] 1922, [in] the case Zucht v. King — lesser known but very important case when we talk about school requirements — the Supreme Court came back and said that a school district was able to exclude a young girl from school when she wasn’t vaccinated, even though there was no active outbreak. 

And so that’s a really, really important case, because if you think about why we require kids to get vaccinated to go to school, it’s a decision that the state makes to impose these requirements so that we don’t have disease outbreaks. It’s the suppression of endemic disease. You take those requirements away, you weaken those requirements, you’re going to see outbreaks potentially. And we’ve seen that with measles outbreaks, where we weaken those policies. 

So it sounds to me less like RFK can put out a mandate that schools federally cannot require vaccines, but more that there could be a trickle-down effect of some of what he does at the federal level, and that might impact then state policies. Is that correct?

Well, yes, but this is something I’m thinking a lot about right now because there is this statute that some of us have looked at over time — — which is the old isolation and quarantine statute that allows, essentially, the CDC to come in and and impose certain measures when necessary to control communicable disease. 

And every semester, I ask students, “Would this actually allow the federal government to impose a vaccine mandate?” And we debate that endlessly, whether that language actually would allow it or not. 

And right now, I think that poses the question: there is preemption language in that statute, so could it potentially be used to set a policy that would undermine state requirements or weaken state requirements? And it’s just a really interesting academic question. I don’t know that realistically that’s something that RFK or the CDC would pursue, but I think we’re living in an era where everything’s on the table.

Well, all of that said, how likely is Kennedy to actually get confirmed? And could there be, from a policy or a legal standpoint, any roadblocks put up in his way?

Yeah, so I do think he’ll get confirmed. I think that what you have seen is President Trump came forward and put together a slate of nominees very rapidly. And all of the ways that you could say that President Trump is inconsistent, he has been very consistent with his health nominees — a lot of similarly held views, a lot of unconventional backgrounds. 

I think just if you look at the pool of appointments as a whole, there’s a lot to take aim at, whether it was Matt Gaetz, his AG nominee () or the selection of the defense secretary nominee (), there’s a lot to provide sort of political fog. And I think that in all of that noise you lose sight of the fact that RFK does not have really the ideal qualifications for the role [and] holds some views that are anti-science. 

And you look to the Senate and ask, “Well, is someone going to stand up and push back and say, ‘We’re not going to confirm this nominee because they lack the qualifications?’” … No one has come out and sort of put a stake in the ground and said, “We’re not going to confirm nominees who don’t meet these qualifications,” or “If they hold these views, there’s no way that they’re going to get a hearing.” 

We just haven’t seen that. And so I do think they’ll get confirmed. I think President Trump expects loyalty from his party.