The Donkey Route as a Public Health Crisis: Mental Health, Family Trauma, and Structural Vulnerability in South Asian Migration to the United States

The Donkey Route as a Public Health Crisis: Mental Health, Family Trauma, and Structural Vulnerability in South Asian Migration to the United States | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Donkey Route as a Public Health Crisis: Mental Health, Family Trauma, and Structural Vulnerability in South Asian Migration to the United States Hari Koirala, Prajita Koirala This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9593505/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Irregular migration routes have expanded globally, yet their public health impacts remain understudied. The "donkey route" (dunki) is a clandestine, multi-continent pathway through South America, Central America, and Mexico used by South Asian migrants attempting to reach the United States. Its use has grown significantly, with thousands of South Asian migrants now encountered annually at the U.S. southern border. Despite its dangers, little research has examined its mental health consequences at individual, family, and structural levels. Methods This article draws on community-based observations developed through a decade of direct engagement with South Asian migrant communities across the United States, including informal discussions, longitudinal follow-up, and direct service provision. Findings are integrated with existing literature on migration, trauma, and structural vulnerability. All narratives are anonymized and presented in composite form. Results Three themes emerged. First, the journey itself produced complex trauma through sustained exposure to violence, extortion, detention, and life-threatening environments. Second, migrants and their families both suffered lasting psychological harm; migrants through demoralization, guilt, and shame; families through financial stress, stigma, and chronic anxiety. Third, post-arrival stressors including undocumented status, labor exploitation, fraudulent legal services, and years-long court delays extended and deepened this harm. Conclusions The donkey route is a preventable public health crisis sustained by policy failure. Enforcement-alone approaches do not stop migration; they make it deadlier. Effective responses must include expanded legal pathways, faster immigration courts, accountability for fraudulent service providers, culturally responsive mental health care, and transnational action on exploitative debt. irregular migration donkey route mental health South Asian immigrants immigration policy structural vulnerability transnational family Figures Figure 1 Background Irregular migration has expanded rapidly as a global phenomenon, yet its consequences for mental health remain poorly understood and underexamined in public health research. Policy responses have focused overwhelmingly on security and enforcement, leaving the health burden on migrants and their families largely invisible and unaddressed. 12 Among irregular pathways, the "donkey route" (dunki in Hindi) has emerged as one of the most dangerous. It involves multi-stage migration from South Asia through South America, the Darién Gap between Colombia and Panama, Central America, and Mexico, before crossing into the United States. The route typically spans 8 to 18 months across 8 or more countries. Between fiscal year 2021 and August 2024, U.S. Customs and Border Protection encountered over 274,000 undocumented immigrants from India alone at the southern border, with Nepali migrants representing a growing share of this flow. These numbers reflect only those who were counted, those who survived to reach a checkpoint. 679 Existing research documents elevated mental health risks among irregular migrants broadly, including PTSD rates of 30–34% among Central American populations and depression rates of 8–29% among undocumented populations. However, South Asian migrants using the donkey route remain almost entirely absent from this literature. Their specific trauma exposures, the transnational financial structures that entrap families in origin countries, and the compounding effect of post-arrival legal vulnerability have not been systematically examined. 145 This gap matters because the donkey route is not declining, it is growing. Without public health documentation of its consequences, policy responses will continue to focus on deterrence alone, missing the preventable mental health burden this pathway produces across two continents. This paper draws on a decade of community-embedded engagement with South Asian migrant populations in the United States to identify these patterns and make them visible to researchers, clinicians, and policymakers. Methods This paper is based on community-engaged observations developed through sustained interaction with South Asian migrant communities across the United States between 2015 and 2024. The lead author is a Nepali immigrant and public health researcher with seventeen years of U.S. residence who has maintained ongoing community-embedded engagement with South Asian migrant populations throughout this period. Insights are based on informal discussions, longitudinal follow-up, and direct service provision, including assistance with housing, employment navigation, and legal referrals, integrated with existing peer-reviewed literature on migration, trauma, and structural vulnerability. More than twenty individuals with direct experience of the donkey route contributed to the understanding reflected in this paper through conversations occurring over this period; six to seven were followed closely over multiple years. Rather than constituting a formal qualitative study with systematic sampling or structured data collection, this work represents an interpretive synthesis of lived experiences encountered in community settings. This approach prioritizes contextual depth and ecological validity but does not aim to produce statistically generalizable findings. All narratives are anonymized and presented in composite form to protect individual identities. Ethics and consent. This study did not involve formal data collection under a research protocol and did not constitute human subjects research as defined by 45 CFR 46. All narrative accounts are anonymized and presented in composite form. Written authorization was obtained where specific accounts informed the analysis. Formal IRB review was not required. Results Four themes emerged from community-based observations integrated with existing literature. Together they describe a multi-level public health burden that begins before departure, intensifies during the journey, continues after arrival, and extends across transnational family networks. Figure 1 Illustrates how these themes connect and compound each other. Figure 1. Four interconnected themes contributing to the public health burden of the donkey route. Solid theme boxes show distinct areas of harm; arrows show pathways of interaction and compounding between themes. All four contribute to a multi-level public health burden affecting migrants, families, and communities across two continents. Theme 1: Cumulative Trauma During Migration Accounts consistently describe prolonged exposure to violence, extortion, detention, and life-threatening environmental conditions across journeys spanning 8 to 18 months and 8 or more countries. Recurrent experiences include witnessing the deaths of fellow travelers, physical violence and robbery, extreme environmental deprivation including dehydration and exposure, and forcible detention in overcrowded facilities in transit countries. These patterns align with established understandings of complex trauma, sustained, repeated exposure to multiple life-threatening situations over extended periods, and are consistent with documented symptoms including intrusive memories, hypervigilance, avoidance behaviors, and persistent physiological distress. 4678 The financial structure of migration amplifies trauma exposure. Smuggling costs for Nepali migrants typically range from $ 25,000 to $ 60,000, financed through family asset liquidation and informal lending at interest rates exceeding 36% annually. As journey costs escalate unexpectedly, a common and deliberately structured feature of smuggling networks, migrants face escalating pressure to continue regardless of worsening conditions, because turning back means returning to families now deeply in debt with nothing to show for the sacrifice. This entrapment dynamic extends trauma exposure and removes the possibility of protective decision-making. 67 The infrastructure of smuggling networks further compounds harm. Networks pass migrants between handlers at each stage, each demanding additional payment. Migrants are warehoused in unsafe conditions in transit, subjected to extortion at border crossings, and provided minimal support during the most dangerous segments of the journey. Deaths during transit, in jungle environments, river crossings, desert passages, are common but rarely documented, as remains are left in remote locations and families may never receive confirmation of what occurred. 81516 Theme 2: Psychological Distress and Demoralization Beyond acute trauma, accounts reflect sustained psychological burden linked to prolonged uncertainty, unmet expectations, and the weight of family obligation. Demoralization, the perception that suffering is meaningless and that sacrifice has harmed rather than helped those they care about, is a consistently observed pattern, particularly among those whose migration outcomes did not meet family expectations. Feelings of shame and guilt are common, intensified in South Asian cultural contexts where individual success and failure are understood as family success and failure. 5 Limited access to mental health services substantially compounds distress. Migrants in transit countries have no access to any mental health support. Upon arrival in the United States, undocumented status, language barriers, cultural stigma around mental health help-seeking, and the prohibitive cost of services together create near-total barriers to care. Suicide, while rarely documented in official statistics, is consistently acknowledged in community testimony as an ongoing and uncounted burden in this population. 15 Theme 3: Transnational Family Impacts The financial structure of migration extends its consequences far beyond the individual migrant. Families in origin countries, particularly in Nepal and other South Asian source regions, frequently experience economic strain, social stigma, and psychological distress that begins at departure and persists throughout the journey, which may last years. Asset liquidation, including the sale of ancestral land and jewelry that carry both economic and identity significance, and borrowing from informal lenders at high compound interest rates, creates debt burdens that cannot be serviced through local employment even if the migration ultimately succeeds. 12 These dynamics suggest a form of transnational secondary trauma, in which the consequences of migration are distributed across family networks and communities. Wives, parents, and children who remain in origin countries experience chronic anxiety about the migrant's safety, management of debt and debt collectors, social stigma in close-knit communities, and prolonged ambiguous loss, neither knowing whether to grieve nor to hope. These effects are compounded by communication patterns in which migrants routinely conceal their true situation to protect family members, creating ongoing information asymmetry and delayed processing of harm. Theme 4: Post-Arrival Structural Vulnerability Following arrival, migrants commonly face precarious legal status, exploitative labor conditions, and systematic barriers to healthcare. Undocumented status creates conditions of chronic stress: inability to work legally, inability to travel internationally, inability to reunite with family members, and constant threat that any policy change may revoke temporary protections. Workplace exploitation, below-minimum-wage cash payment, denial of overtime, unsafe conditions, and implicit or explicit threats of immigration reporting, is documented and consistent with broader research on undocumented immigrant labor conditions. 15 Exposure to fraudulent immigration legal services is a specific and particularly harmful structural vulnerability documented in this community. Unlicensed individuals posing as immigration attorneys operate openly within South Asian immigrant communities, advertising on social media platforms and community networks, charging $ 3,000 to $ 15,000 for promised services that are not delivered or that result in fraudulent filings destroying legitimate asylum claims. The Federal Trade Commission issued a consumer alert in 2024 specifically warning that individuals were impersonating lawyers and court officials on social media to defraud immigrants. 1213 Prolonged immigration court proceedings, including a documented backlog of 3.7 million cases, and average resolution times of 4 to 7 years as of late 2024, contribute to chronic uncertainty and ongoing psychological stress that compounds earlier trauma. This extended legal limbo, during which migrants may hold fragile work authorizations requiring periodic renewal, constitutes a sustained public health burden for a population with almost no access to mental health services. 1011 Discussion These observations position the donkey route as a multi-level public health issue affecting individuals, families, and communities across two continents. The findings are consistent with broader literature on migration-related trauma while highlighting specific dynamics within South Asian migration pathways that deserve dedicated research and clinical attention. The concept of structural vulnerability is central to understanding these outcomes. Health risks are shaped not only by what migrants experience directly, but by systemic conditions that constrain safe mobility, remove the possibility of protective decision-making, and limit access to care and legal protection at every stage of the migration process. The absence of legal migration pathways drives demand for dangerous illegal routes. The predatory financial structures of smuggling networks entrap families. Post-arrival legal systems create years of uncertainty that compound earlier trauma. Each of these is a policy-created condition, not a natural feature of migration. Enforcement-centered approaches, border walls, surveillance, detention, prosecution of smugglers, address none of the underlying conditions that create demand for the donkey route. Research consistently shows that intensified enforcement does not reduce irregular migration; it redirects migrants toward more dangerous and more expensive pathways, increasing mortality and deepening exploitation while generating greater profit for smuggling networks. The public health community has a responsibility to name this clearly: enforcement without alternatives is not a neutral policy, it is a policy that predictably increases harm. Several limitations of this analysis should be acknowledged. This work is based on community-engaged observation rather than systematic research and is not designed to produce statistically generalizable findings. Accounts are retrospective and may be subject to recall limitations. The population encountered is not a representative sample of all donkey route migrants. The interpretive synthesis reflects the author's community-embedded perspective, which provides contextual depth and access to narratives that external researchers cannot readily obtain, but also introduces positionality that readers should consider. Formal qualitative and epidemiological research with systematic sampling is needed to build on the patterns identified here. Policy Implications Addressing these challenges requires coordinated public health and policy responses across multiple domains: Expansion of legal migration pathways to reduce reliance on high-risk irregular routes and remove the structural conditions that make dangerous migration the only perceived option for working-class migrants from countries like Nepal. Immigration system reform to substantially reduce court backlogs and resolution timelines, decreasing the duration of legal limbo that constitutes ongoing psychological harm for asylum-seeking populations. Stronger oversight and enforcement against fraudulent immigration legal service providers, with recognition by public health agencies that immigration fraud constitutes a specific and documented health hazard. Increased investment in culturally and linguistically appropriate mental health services for irregular migrant populations, including training for providers serving South Asian communities in migration-specific trauma presentations. Transnational cooperation with source country governments and financial regulators to address exploitative informal lending practices that finance migration and create lasting family-level harm. Conclusions The donkey route represents an underrecognized public health challenge with significant mental health and transnational consequences. Its impacts extend beyond immediate physical risks to include long-term psychological distress, family dissolution, and community-level economic and social harm. These consequences are not incidental to the route; they are its standard product for the majority of those who travel it and the families who finance the journey. A shift toward health-informed migration policy is necessary to reduce preventable harm and improve outcomes for affected populations. Enforcement without alternatives does not deter irregular migration, it makes migration more dangerous, more expensive, and more profitable for criminal networks, while concentrating its health consequences in populations that are already among the most vulnerable and least served by existing health systems. Sustained community-based observation of the kind reported here, integrated with formal qualitative and epidemiological research, is needed to build the evidence base required to inform policy change. The public health community has a responsibility to recognize and respond to migration-related health burdens that current policy frameworks make invisible. Declarations Ethics and Consent Statement This study is based on community-engaged observations and did not involve formal data collection under a research protocol. It did not constitute human subjects research as defined by 45 CFR 46. All narratives are anonymized and presented in composite form. Written authorization was obtained where specific accounts informed the analysis. Formal IRB review was not required. Competing interests: The author declares no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contributions: Hari Koirala conducted all community engagement, synthesized observations with existing literature, and wrote the manuscript in its entirety. Availability of data and materials: All data are anonymized community observations. No dataset is available for sharing. Requests for further information may be directed to the corresponding author. References World Health Organization. Refugee and migrant health [Fact Sheet]. Geneva: WHO; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health International Organization for Migration. World Migration Report 2024. Geneva: IOM; 2024. Available from: https://worldmigrationreport.iom.int Kuo, Ben C H. “Coping, acculturation, and psychological adaptation among migrants: a theoretical and empirical review and synthesis of the literature.” Health psychology and behavioral medicine vol. 2,1 (2014): 16-33. doi:10.1080/21642850.2013.843459 National Institutes of Health/PMC. Stress, trauma, and post-traumatic stress disorder in migrants: a comprehensive review [multiple studies 2017–2023]. Bethesda: NIH; 2023. Available from: https://www.ncbi.nlm.nih.gov/pmc Journal of Immigrant and Minority Health. Psychological distress among undocumented immigrants [multiple studies 2018–2023]. New York: Springer; 2023. Available from: https://www.springer.com/journal/10903 Human Rights Watch. Darién Gap: Humanitarian Crisis on Migration Route. New York: HRW; 2023. Available from: https://www.hrw.org Council on Foreign Relations. The Darién Gap: migration's most dangerous route. New York: CFR; 2024 Jul. Available from: https://www.cfr.org/article/darien-gap-migration-route The New Humanitarian. Record numbers cross deadly Darién Gap. Geneva: TNH; 2024. Available from: https://www.thenewhumanitarian.org U.S. Customs and Border Protection. Southwest Land Border Encounters, Fiscal Year 2021–2024. Washington DC: CBP; 2024. Available from: https://www.cbp.gov/newsroom/stats/southwest-land-border-encounters TRAC Immigration, Syracuse University. Immigration Court Backlog Tool [Internet]. Syracuse: TRAC; 2024 Oct [cited 2025 Apr]. Available from: https://trac.syr.edu/immigration American Immigration Council. The immigration court system. Washington DC: AIC; 2024. Available from: https://www.americanimmigrationcouncil.org Federal Trade Commission. People on social media are pretending to be lawyers — and even court officials [Consumer Alert]. Washington DC: FTC; 2024 Apr. Available from: https://consumer.ftc.gov U.S. Department of Justice. Immigration fraud prosecutions 2024 [press releases]. Washington DC: DOJ; 2024. Available from: https://www.justice.gov American Bar Association. Immigration fraud and unauthorized practice of law. Chicago: ABA; 2024. Available from: https://www.americanbar.org UNODC. Transnational organized crime in Central America and the Caribbean: a threat assessment. Vienna: UNODC; 2023. Available from: https://www.unodc.org INTERPOL. Operation Storm Makers and anti-smuggling operations [press releases]. Lyon: INTERPOL; 2023–2024. Available from: https://www.interpol.int Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9593505","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634072324,"identity":"3b69ad78-b72f-48be-9117-9e60402312b4","order_by":0,"name":"Hari Koirala","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACAyA+2MAgwcDAzsDAzMBgwwBiE6mFGYzSiNPC2ABiQbQcJqzFnP3sw4MzKizy+ZuZHzAX7jif2D+7+eADhhqbaFxaLHvSDQ5uOCNhOeMwmwHzzDO3E2fcOZZswHAsLbcBl8MOpDEcfNgmYQB0kgEzb9vtxIYbOWYSjA2HcWs5/wyiRf4w+weglnOJ8wlquQG0ZSNQi8FhHpAtBxI3ENYCtGXGGQkDw8M8Bcy8Z5KNN95ISzZIwOeX82nMH3sq6gzkjrdvYObdYSc770bywQcfamxwakEG7D+AMeQIVplAhHIIAGqxJ1rxKBgFo2AUjBgAABE3Xj7a0PDvAAAAAElFTkSuQmCC","orcid":"","institution":"American College of Education","correspondingAuthor":true,"prefix":"","firstName":"Hari","middleName":"","lastName":"Koirala","suffix":""},{"id":634072325,"identity":"9fac1f38-7e48-4bd6-b89b-3797cf17b160","order_by":1,"name":"Prajita Koirala","email":"","orcid":"","institution":"University of Missouri","correspondingAuthor":false,"prefix":"","firstName":"Prajita","middleName":"","lastName":"Koirala","suffix":""}],"badges":[],"createdAt":"2026-05-02 11:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9593505/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9593505/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108467678,"identity":"01d0ee9e-997d-4b4e-b2d3-0c81c9b647ef","added_by":"auto","created_at":"2026-05-05 04:20:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107694,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eIllustrates how these themes connect and compound each other.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFour interconnected themes contributing to the public health burden of the donkey route. Solid theme boxes show distinct areas of harm; arrows show pathways of interaction and compounding between themes. All four contribute to a multi-level public health burden affecting migrants, families, and communities across two continents.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9593505/v1/d9e56b743d1646ee755a1612.png"},{"id":108496610,"identity":"2a2832a3-6ddf-44fb-980d-9067caeff082","added_by":"auto","created_at":"2026-05-05 10:12:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":252690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9593505/v1/a3e52da6-c433-48e1-a75c-16c00e4a6310.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Donkey Route as a Public Health Crisis: Mental Health, Family Trauma, and Structural Vulnerability in South Asian Migration to the United States","fulltext":[{"header":"Background","content":"\u003cp\u003eIrregular migration has expanded rapidly as a global phenomenon, yet its consequences for mental health remain poorly understood and underexamined in public health research. Policy responses have focused overwhelmingly on security and enforcement, leaving the health burden on migrants and their families largely invisible and unaddressed.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAmong irregular pathways, the \"donkey route\" (dunki in Hindi) has emerged as one of the most dangerous. It involves multi-stage migration from South Asia through South America, the Dari\u0026eacute;n Gap between Colombia and Panama, Central America, and Mexico, before crossing into the United States. The route typically spans 8 to 18 months across 8 or more countries. Between fiscal year 2021 and August 2024, U.S. Customs and Border Protection encountered over 274,000 undocumented immigrants from India alone at the southern border, with Nepali migrants representing a growing share of this flow. These numbers reflect only those who were counted, those who survived to reach a checkpoint.\u003csup\u003e679\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExisting research documents elevated mental health risks among irregular migrants broadly, including PTSD rates of 30\u0026ndash;34% among Central American populations and depression rates of 8\u0026ndash;29% among undocumented populations. However, South Asian migrants using the donkey route remain almost entirely absent from this literature. Their specific trauma exposures, the transnational financial structures that entrap families in origin countries, and the compounding effect of post-arrival legal vulnerability have not been systematically examined.\u003csup\u003e145\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis gap matters because the donkey route is not declining, it is growing. Without public health documentation of its consequences, policy responses will continue to focus on deterrence alone, missing the preventable mental health burden this pathway produces across two continents. This paper draws on a decade of community-embedded engagement with South Asian migrant populations in the United States to identify these patterns and make them visible to researchers, clinicians, and policymakers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis paper is based on community-engaged observations developed through sustained interaction with South Asian migrant communities across the United States between 2015 and 2024. The lead author is a Nepali immigrant and public health researcher with seventeen years of U.S. residence who has maintained ongoing community-embedded engagement with South Asian migrant populations throughout this period.\u003c/p\u003e \u003cp\u003eInsights are based on informal discussions, longitudinal follow-up, and direct service provision, including assistance with housing, employment navigation, and legal referrals, integrated with existing peer-reviewed literature on migration, trauma, and structural vulnerability. More than twenty individuals with direct experience of the donkey route contributed to the understanding reflected in this paper through conversations occurring over this period; six to seven were followed closely over multiple years.\u003c/p\u003e \u003cp\u003eRather than constituting a formal qualitative study with systematic sampling or structured data collection, this work represents an interpretive synthesis of lived experiences encountered in community settings. This approach prioritizes contextual depth and ecological validity but does not aim to produce statistically generalizable findings. All narratives are anonymized and presented in composite form to protect individual identities.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthics and consent.\u003c/b\u003e This study did not involve formal data collection under a research protocol and did not constitute human subjects research as defined by 45 CFR 46. All narrative accounts are anonymized and presented in composite form. Written authorization was obtained where specific accounts informed the analysis. Formal IRB review was not required.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFour themes emerged from community-based observations integrated with existing literature. Together they describe a multi-level public health burden that begins before departure, intensifies during the journey, continues after arrival, and extends across transnational family networks.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIllustrates how these themes connect and compound each other.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 1. Four interconnected themes contributing to the public health burden of the donkey route. Solid theme boxes show distinct areas of harm; arrows show pathways of interaction and compounding between themes. All four contribute to a multi-level public health burden affecting migrants, families, and communities across two continents.\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eTheme 1: Cumulative Trauma During Migration\u003c/h3\u003e\n\u003cp\u003eAccounts consistently describe prolonged exposure to violence, extortion, detention, and life-threatening environmental conditions across journeys spanning 8 to 18 months and 8 or more countries. Recurrent experiences include witnessing the deaths of fellow travelers, physical violence and robbery, extreme environmental deprivation including dehydration and exposure, and forcible detention in overcrowded facilities in transit countries. These patterns align with established understandings of complex trauma, sustained, repeated exposure to multiple life-threatening situations over extended periods, and are consistent with documented symptoms including intrusive memories, hypervigilance, avoidance behaviors, and persistent physiological distress.\u003csup\u003e4678\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe financial structure of migration amplifies trauma exposure. Smuggling costs for Nepali migrants typically range from \u003cspan\u003e$\u003c/span\u003e25,000 to \u003cspan\u003e$\u003c/span\u003e60,000, financed through family asset liquidation and informal lending at interest rates exceeding 36% annually. As journey costs escalate unexpectedly, a common and deliberately structured feature of smuggling networks, migrants face escalating pressure to continue regardless of worsening conditions, because turning back means returning to families now deeply in debt with nothing to show for the sacrifice. This entrapment dynamic extends trauma exposure and removes the possibility of protective decision-making.\u003csup\u003e67\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe infrastructure of smuggling networks further compounds harm. Networks pass migrants between handlers at each stage, each demanding additional payment. Migrants are warehoused in unsafe conditions in transit, subjected to extortion at border crossings, and provided minimal support during the most dangerous segments of the journey. Deaths during transit, in jungle environments, river crossings, desert passages, are common but rarely documented, as remains are left in remote locations and families may never receive confirmation of what occurred.\u003csup\u003e81516\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 2: Psychological Distress and Demoralization\u003c/h3\u003e\n\u003cp\u003eBeyond acute trauma, accounts reflect sustained psychological burden linked to prolonged uncertainty, unmet expectations, and the weight of family obligation. Demoralization, the perception that suffering is meaningless and that sacrifice has harmed rather than helped those they care about, is a consistently observed pattern, particularly among those whose migration outcomes did not meet family expectations. Feelings of shame and guilt are common, intensified in South Asian cultural contexts where individual success and failure are understood as family success and failure.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLimited access to mental health services substantially compounds distress. Migrants in transit countries have no access to any mental health support. Upon arrival in the United States, undocumented status, language barriers, cultural stigma around mental health help-seeking, and the prohibitive cost of services together create near-total barriers to care. Suicide, while rarely documented in official statistics, is consistently acknowledged in community testimony as an ongoing and uncounted burden in this population.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 3: Transnational Family Impacts\u003c/h3\u003e\n\u003cp\u003eThe financial structure of migration extends its consequences far beyond the individual migrant. Families in origin countries, particularly in Nepal and other South Asian source regions, frequently experience economic strain, social stigma, and psychological distress that begins at departure and persists throughout the journey, which may last years. Asset liquidation, including the sale of ancestral land and jewelry that carry both economic and identity significance, and borrowing from informal lenders at high compound interest rates, creates debt burdens that cannot be serviced through local employment even if the migration ultimately succeeds.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThese dynamics suggest a form of transnational secondary trauma, in which the consequences of migration are distributed across family networks and communities. Wives, parents, and children who remain in origin countries experience chronic anxiety about the migrant's safety, management of debt and debt collectors, social stigma in close-knit communities, and prolonged ambiguous loss, neither knowing whether to grieve nor to hope. These effects are compounded by communication patterns in which migrants routinely conceal their true situation to protect family members, creating ongoing information asymmetry and delayed processing of harm.\u003c/p\u003e\n\u003ch3\u003eTheme 4: Post-Arrival Structural Vulnerability\u003c/h3\u003e\n\u003cp\u003eFollowing arrival, migrants commonly face precarious legal status, exploitative labor conditions, and systematic barriers to healthcare. Undocumented status creates conditions of chronic stress: inability to work legally, inability to travel internationally, inability to reunite with family members, and constant threat that any policy change may revoke temporary protections. Workplace exploitation, below-minimum-wage cash payment, denial of overtime, unsafe conditions, and implicit or explicit threats of immigration reporting, is documented and consistent with broader research on undocumented immigrant labor conditions.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eExposure to fraudulent immigration legal services is a specific and particularly harmful structural vulnerability documented in this community. Unlicensed individuals posing as immigration attorneys operate openly within South Asian immigrant communities, advertising on social media platforms and community networks, charging \u003cspan\u003e$\u003c/span\u003e3,000 to \u003cspan\u003e$\u003c/span\u003e15,000 for promised services that are not delivered or that result in fraudulent filings destroying legitimate asylum claims. The Federal Trade Commission issued a consumer alert in 2024 specifically warning that individuals were impersonating lawyers and court officials on social media to defraud immigrants.\u003csup\u003e1213\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eProlonged immigration court proceedings, including a documented backlog of 3.7\u0026nbsp;million cases, and average resolution times of 4 to 7 years as of late 2024, contribute to chronic uncertainty and ongoing psychological stress that compounds earlier trauma. This extended legal limbo, during which migrants may hold fragile work authorizations requiring periodic renewal, constitutes a sustained public health burden for a population with almost no access to mental health services.\u003csup\u003e1011\u003c/sup\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThese observations position the donkey route as a multi-level public health issue affecting individuals, families, and communities across two continents. The findings are consistent with broader literature on migration-related trauma while highlighting specific dynamics within South Asian migration pathways that deserve dedicated research and clinical attention.\u003c/p\u003e \u003cp\u003eThe concept of structural vulnerability is central to understanding these outcomes. Health risks are shaped not only by what migrants experience directly, but by systemic conditions that constrain safe mobility, remove the possibility of protective decision-making, and limit access to care and legal protection at every stage of the migration process. The absence of legal migration pathways drives demand for dangerous illegal routes. The predatory financial structures of smuggling networks entrap families. Post-arrival legal systems create years of uncertainty that compound earlier trauma. Each of these is a policy-created condition, not a natural feature of migration.\u003c/p\u003e \u003cp\u003eEnforcement-centered approaches, border walls, surveillance, detention, prosecution of smugglers, address none of the underlying conditions that create demand for the donkey route. Research consistently shows that intensified enforcement does not reduce irregular migration; it redirects migrants toward more dangerous and more expensive pathways, increasing mortality and deepening exploitation while generating greater profit for smuggling networks. The public health community has a responsibility to name this clearly: enforcement without alternatives is not a neutral policy, it is a policy that predictably increases harm.\u003c/p\u003e \u003cp\u003eSeveral limitations of this analysis should be acknowledged. This work is based on community-engaged observation rather than systematic research and is not designed to produce statistically generalizable findings. Accounts are retrospective and may be subject to recall limitations. The population encountered is not a representative sample of all donkey route migrants. The interpretive synthesis reflects the author's community-embedded perspective, which provides contextual depth and access to narratives that external researchers cannot readily obtain, but also introduces positionality that readers should consider. Formal qualitative and epidemiological research with systematic sampling is needed to build on the patterns identified here.\u003c/p\u003e\n\u003ch3\u003ePolicy Implications\u003c/h3\u003e\n\u003cp\u003eAddressing these challenges requires coordinated public health and policy responses across multiple domains:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eExpansion of legal migration pathways to reduce reliance on high-risk irregular routes and remove the structural conditions that make dangerous migration the only perceived option for working-class migrants from countries like Nepal.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImmigration system reform to substantially reduce court backlogs and resolution timelines, decreasing the duration of legal limbo that constitutes ongoing psychological harm for asylum-seeking populations.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStronger oversight and enforcement against fraudulent immigration legal service providers, with recognition by public health agencies that immigration fraud constitutes a specific and documented health hazard.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIncreased investment in culturally and linguistically appropriate mental health services for irregular migrant populations, including training for providers serving South Asian communities in migration-specific trauma presentations.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTransnational cooperation with source country governments and financial regulators to address exploitative informal lending practices that finance migration and create lasting family-level harm.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe donkey route represents an underrecognized public health challenge with significant mental health and transnational consequences. Its impacts extend beyond immediate physical risks to include long-term psychological distress, family dissolution, and community-level economic and social harm. These consequences are not incidental to the route; they are its standard product for the majority of those who travel it and the families who finance the journey.\u003c/p\u003e \u003cp\u003eA shift toward health-informed migration policy is necessary to reduce preventable harm and improve outcomes for affected populations. Enforcement without alternatives does not deter irregular migration, it makes migration more dangerous, more expensive, and more profitable for criminal networks, while concentrating its health consequences in populations that are already among the most vulnerable and least served by existing health systems.\u003c/p\u003e \u003cp\u003eSustained community-based observation of the kind reported here, integrated with formal qualitative and epidemiological research, is needed to build the evidence base required to inform policy change. The public health community has a responsibility to recognize and respond to migration-related health burdens that current policy frameworks make invisible.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics and Consent Statement\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study is based on community-engaged observations and did not involve formal data collection under a research protocol. It did not constitute human subjects research as defined by 45 CFR 46. All narratives are anonymized and presented in composite form. Written authorization was obtained where specific accounts informed the analysis. Formal IRB review was not required.\u003c/em\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe author declares no competing interests.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eHari Koirala conducted all community engagement, synthesized observations with existing literature, and wrote the manuscript in its entirety.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data are anonymized community observations. No dataset is available for sharing. Requests for further information may be directed to the corresponding author.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. Refugee and migrant health [Fact Sheet]. Geneva: WHO; 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health\u003c/li\u003e\n \u003cli\u003eInternational Organization for Migration. World Migration Report 2024. Geneva: IOM; 2024. Available from: https://worldmigrationreport.iom.int\u003c/li\u003e\n \u003cli\u003eKuo, Ben C H. \u0026ldquo;Coping, acculturation, and psychological adaptation among migrants: a theoretical and empirical review and synthesis of the literature.\u0026rdquo; \u003cem\u003eHealth psychology and behavioral medicine\u003c/em\u003e vol. 2,1 (2014): 16-33. doi:10.1080/21642850.2013.843459\u003c/li\u003e\n \u003cli\u003eNational Institutes of Health/PMC. Stress, trauma, and post-traumatic stress disorder in migrants: a comprehensive review [multiple studies 2017\u0026ndash;2023]. Bethesda: NIH; 2023. Available from: https://www.ncbi.nlm.nih.gov/pmc\u003c/li\u003e\n \u003cli\u003eJournal of Immigrant and Minority Health. Psychological distress among undocumented immigrants [multiple studies 2018\u0026ndash;2023]. New York: Springer; 2023. Available from: https://www.springer.com/journal/10903\u003c/li\u003e\n \u003cli\u003eHuman Rights Watch. Dari\u0026eacute;n Gap: Humanitarian Crisis on Migration Route. New York: HRW; 2023. Available from: https://www.hrw.org\u003c/li\u003e\n \u003cli\u003eCouncil on Foreign Relations. The Dari\u0026eacute;n Gap: migration\u0026apos;s most dangerous route. New York: CFR; 2024 Jul. Available from: https://www.cfr.org/article/darien-gap-migration-route\u003c/li\u003e\n \u003cli\u003eThe New Humanitarian. Record numbers cross deadly Dari\u0026eacute;n Gap. Geneva: TNH; 2024. Available from: https://www.thenewhumanitarian.org\u003c/li\u003e\n \u003cli\u003eU.S. Customs and Border Protection. Southwest Land Border Encounters, Fiscal Year 2021\u0026ndash;2024. Washington DC: CBP; 2024. Available from: https://www.cbp.gov/newsroom/stats/southwest-land-border-encounters\u003c/li\u003e\n \u003cli\u003eTRAC Immigration, Syracuse University. Immigration Court Backlog Tool [Internet]. Syracuse: TRAC; 2024 Oct [cited 2025 Apr]. Available from: https://trac.syr.edu/immigration\u003c/li\u003e\n \u003cli\u003eAmerican Immigration Council. The immigration court system. Washington DC: AIC; 2024. Available from: https://www.americanimmigrationcouncil.org\u003c/li\u003e\n \u003cli\u003eFederal Trade Commission. People on social media are pretending to be lawyers \u0026mdash; and even court officials [Consumer Alert]. Washington DC: FTC; 2024 Apr. Available from: https://consumer.ftc.gov\u003c/li\u003e\n \u003cli\u003eU.S. Department of Justice. Immigration fraud prosecutions 2024 [press releases]. Washington DC: DOJ; 2024. Available from: https://www.justice.gov\u003c/li\u003e\n \u003cli\u003eAmerican Bar Association. Immigration fraud and unauthorized practice of law. Chicago: ABA; 2024. Available from: https://www.americanbar.org\u003c/li\u003e\n \u003cli\u003eUNODC. Transnational organized crime in Central America and the Caribbean: a threat assessment. Vienna: UNODC; 2023. Available from: https://www.unodc.org\u003c/li\u003e\n \u003cli\u003eINTERPOL. Operation Storm Makers and anti-smuggling operations [press releases]. Lyon: INTERPOL; 2023\u0026ndash;2024. Available from: https://www.interpol.int\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"irregular migration, donkey route, mental health, South Asian immigrants, immigration policy, structural vulnerability, transnational family","lastPublishedDoi":"10.21203/rs.3.rs-9593505/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9593505/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIrregular migration routes have expanded globally, yet their public health impacts remain understudied. The \"donkey route\" (dunki) is a clandestine, multi-continent pathway through South America, Central America, and Mexico used by South Asian migrants attempting to reach the United States. Its use has grown significantly, with thousands of South Asian migrants now encountered annually at the U.S. southern border. Despite its dangers, little research has examined its mental health consequences at individual, family, and structural levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis article draws on community-based observations developed through a decade of direct engagement with South Asian migrant communities across the United States, including informal discussions, longitudinal follow-up, and direct service provision. Findings are integrated with existing literature on migration, trauma, and structural vulnerability. All narratives are anonymized and presented in composite form.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree themes emerged. First, the journey itself produced complex trauma through sustained exposure to violence, extortion, detention, and life-threatening environments. Second, migrants and their families both suffered lasting psychological harm; migrants through demoralization, guilt, and shame; families through financial stress, stigma, and chronic anxiety. Third, post-arrival stressors including undocumented status, labor exploitation, fraudulent legal services, and years-long court delays extended and deepened this harm.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe donkey route is a preventable public health crisis sustained by policy failure. Enforcement-alone approaches do not stop migration; they make it deadlier. Effective responses must include expanded legal pathways, faster immigration courts, accountability for fraudulent service providers, culturally responsive mental health care, and transnational action on exploitative debt.\u003c/p\u003e","manuscriptTitle":"The Donkey Route as a Public Health Crisis: Mental Health, Family Trauma, and Structural Vulnerability in South Asian Migration to the United States","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-05 04:20:54","doi":"10.21203/rs.3.rs-9593505/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"52e26c8c-37e6-4294-935d-9bbe0e85a565","owner":[],"postedDate":"May 5th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-04T10:38:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-04T07:51:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-04T07:26:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Global and Public Health","date":"2026-05-02T11:38:59+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T10:02:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-05 04:20:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9593505","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9593505","identity":"rs-9593505","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}