3Immigration and the Social Determinants of Health

LINKING IMMIGRATION WITH THE SOCIAL DETERMINANTS OF HEALTH

In the past, research on immigrant health has been largely disconnected from the analytical framework provided by the concept of the social determinants of health, pointed out Heide Castañeda, associate professor of anthropology at the University of South Florida. Analyses and interventions of immigrant health have focused “on individual behaviors and purported cultural beliefs rather than on glaring patterns of inequality and pathogenic conditions produced by structures of poverty, immigration policy, and heavy-handed enforcement tactics,” she said.

Throughout prehistory and history, migration has been a fundamental part of the human condition, and “no nation has remained untouched by human mobility,” noted Castañeda. However, considering migration “natural” is misleading and dangerous, she continued, adding:

There's nothing natural about human displacement. Global patterns of inequality that lead to migration are rooted in specific social, political, and economic conditions; they reproduce by specific structures, policies, and institutions; and to gloss over the root causes of population movements is an injustice to the people affected by them.

The world is currently witnessing the highest ever recorded number of international migrants at 244 million, though the percentage of the world's population who are migrants has remained fairly constant over the past several decades, at about 3 percent. In addition, migration occurs within countries, and many individuals have become trapped in third countries during transit from one country to another. About 66 million people worldwide have been forcibly displaced from their homes, although scholars are challenging the dichotomy between voluntary and involuntary migration, noted Castañeda. For example, they are arguing that people can also be forcibly displaced through poverty in their home countries.

The framing of the causes of migration is important, Castañeda said, because it affects a group's reception in a country, which in turn can affect the health status of immigrants. This is why a focus on structural factors is important, such as the cost of health care, discrimination, racism, and poor access to transportation. Like gender or race, immigration status represents another form of everyday inequality that may be pervasive and inescapable.

Immigration can thus be both a consequence of social determinants and a social determinant in its own right, said Castañeda. Understanding this relationship may require going beyond the hold of individualism and behaviorism in scientific studies and interventions and instead tackling a wider sphere of upstream structural factors that affect health, including living and working conditions; income inequalities and poverty; access to care; immigration policies and enforcement practices; and gender, race, and ethnic hierarchies. This approach draws insights from political economy, critical race theory, structural violence, structural vulnerability, and intersectionality, but it tries to avoid strict delineations of variables upon operationalization. “The more we fix and make permanent the specific factors in our definitions, the more likely we are to lose the big picture and the radical reframing that needs to be done,” she explained.

In a meta-analysis that appeared in the Annual Review of Public Health (Castañeda et al., 2015), Castañeda and her colleagues reviewed articles on immigration and health published since 2000 and found that most focused on behavioral and cultural factors. Consideration of structural factors was more limited, focusing most often on access to care. Access to care varies among immigrant populations, with undocumented immigrants typically having extremely limited access to care, which “impacts well-being significantly,” Castañeda said. Study of federal policies from a social determinants of health perspective can help reveal policies that have constrained access to care for immigrants, as well as the broader effects of immigration status. For example, how does exclusion from certain labor protections, which affects other low-income populations of color, uniquely affect immigrants? How do the direct consequences of immigration enforcement activities, such as detention, deportation, and family separation, affect health? She concluded that a lack of dialogue between people working in areas involved with the social determinants of health and people working on immigration issues has resulted in missed opportunities for research, practice, and policy.

As an example of this broader approach, Castañeda cited her work on immigrant communities in South Texas. Rates of diabetes are extremely high in this region, which had attracted researchers interested in genetic or dietary causes of diabetes. But this research has tended to overlook the roles of policies that have limited the economic opportunities, dislocated communities, and affected housing, all of which contribute to pathogenic conditions. “The rates of diabetes there are no coincidence,” said Castañeda.

She concluded by listing several research priorities and gaps that are based on this broader focus on structural factors. New anti-immigrant policies and heightened enforcement are affecting the health of communities, she said. For example, she has been looking at the developmental implications for children when a family member is detained or deported. The effects of uncertain legal status should be better understood, she said, as should the ripple effects of legal status on family members, including U.S. citizens. An issue that needs to be examined, for example, is the rising mental health toll for DACA recipients since the program was rescinded.

The effects of local immigration, health, labor, and education policies have also been underexplored, Castañeda noted. Many states have adopted policies involving farm worker organizing, higher minimum wages, identification cards, and driver's license eligibility for immigrants, and the effects of these changes could be further explored. Finally, she emphasized studying resiliency despite factors that affect individual and community health. “This represents a strength-based approach as opposed to the more common deficit focus in health research,” said Castañeda, which is a trap into which even a social determinants approach can fall. Resiliency studies could include analyses of social capital, informal care networks, community organizing, and practices that preserve healthy communities. For example, not all DACA recipients are experiencing mental stress when confronted with the possibilities of becoming undocumented again. Castañeda noted, “I would say half are [stressed] and the other half are saying, ‘You know what, we got this, we've been there before, and now we have more skills and better networks.' That's a resiliency perspective.”

A social determinants of health approach can be difficult to employ because it is political—“and by political, I don't mean partisan, but that it requires the buy-in of policy makers to create change,” she stated. Change based on this approach may require inclusive health care practices, engagement with immigration communities, and advocacy for fair immigration economic and health policies. Castañeda concluded with “it requires commitment and a true desire for change.”

A STATE SURVEY OF HEALTH

California is home to about 4 percent of the 240 million people worldwide who live outside their countries of origin, noted Ninez Ponce, professor in the University of California, Los Angeles (UCLA), Fielding School of Public Health's Department of Health Policy and Management, associate center director of the UCLA Center for Health Policy Research, and director of the UCLA Center for Global and Immigrant Health. More than one in four Californians is an immigrant—amounting to more than 10 million people—compared with less than one in seven for the United States as a whole.

The California Health Interview Survey (CHIS), which was launched in 2001 and interviews more than 20,000 adults, teenagers, and children each year, is the largest continuous state-based health survey in the United States and the most comprehensive source of data on California's diverse population. It was designed from the ground up to provide data that are used for governance, health systems, and wider system accountability at the local and statewide levels and also to provide new knowledge. It seeks to understand the social determinants of health not just at a policy level but at an individual level, with geocoding allowing for linkages with measures of neighborhood context such as pollution, health care supply, or local policies. It is funded by a variety of state and local agencies, Californian and national foundations, and others. This mix of public and private funding facilitates the nimble inclusion of hot topics, said Ponce, while also ensuring a population-based perspective. “Getting at an emerging crisis could avert a costly burden on the health system,” she added.

CHIS uses a random digit dial telephone survey—including cell phones since 2007—to provide statistically reliable estimates. Response rates have been going down, but the sample is still representative of the California population, said Ponce. It is conducted in seven different languages—Chinese (Cantonese and Mandarin), English, Korean, Spanish, Tagalog, and Vietnamese—and new languages are considered following the release of census data. Some ethnic groups are oversampled, including Alaskan Natives, American Indians, Japanese, Koreans, and Vietnamese. Adults speak for their minor children and give permission to collect information on teens. Interviews can take 35 minutes for adults, 20 minutes for adolescents, and 15 minutes for children.

For immigrant populations, CHIS is a tool for understanding their health needs and inequities in health and economic well-being. It looks at social factors, health care access, health behaviors, and health conditions (see Figure 3-1). It also includes information on language, race and ethnicity, citizenship and immigration status, and how long a family has been in the United States, including country of birth and the mother's and father's country of birth. Since the launch of CHIS in 2001, it asks:

FIGURE 3-1

The California Health Interview Survey (CHIS) examines not only health conditions and behaviors but the social and economic factors that can affect those conditions and behaviors. SOURCES: Ponce, 2017. Figure created based on CHIS information: http://healthpolicy.ucla.edu/chis/design/pages/survey-topics.aspx (more...)

• Are you a citizen of the United States?
• Are you a permanent resident with a green card? Your answers are confidential and will not be reported to Immigration Services.
• About how many years have you lived in the United States?

In 2015–2016, specific questions on immigration were added:

• In what year did you become naturalized?
• Tell me if you are currently here on any of the following: a tourist visa, a student visa, a work visa or permit, or another document that permits you to stay in the U.S. for a limited amount of time?
• Was this visa or permit through Deferred Action for Childhood Arrivals or DACA?
• Is this visa or document still valid or has it expired?

These are sensitive and complicated questions, Ponce acknowledged. For example, being a noncitizen could mean a person is not lawfully present, is in the DACA program, or is waiting for a green card. “There's some fuzziness in that,” she said, which is reflected in different ways of calculating the number of undocumented people in California, with estimates ranging from 1.2 million to 1.4 million. As a result of the sensitivities, nonresponse rates for these questions could be higher than most questions, but not as high as other sensitive survey questions such as income. The questions since 2001 post relatively low nonresponse rates (less than 5 percent), but questions on visa type in 2015–2016 register higher nonresponse rates, about 20 percent.

In 2011 the National Council of La Raza, along with more than 200 other civil rights and consumer groups, recommended to the U.S. Department of Health and Human Services that CHIS be used as a model for the collection of data on immigrants and mixed-status families in data collection related to federal health care reform. CHIS has been used to study the effects of language, citizenship, and U.S. tenure on health, health access, and perceived discrimination. It has significantly affected state policy, including laws on health care language assistance, children's health, and medical interpretation services. The survey provides not just numbers but relationships, Ponce concluded, which make its results a particularly valuable social science data set.

COMMUNITY-BASED RESPONSES

La Clínica del Pueblo is a federally qualified health center in the Washington, DC, metropolitan area focused on building a healthy Latino community through culturally appropriate health services, with a particular focus on those most in need. It was founded in 1983 on the concept that health care is a human right. “It still blows me away that we have to say that out loud, but we do,” said the organization's executive director, Alicia Wilson.

In the primary area the clinic serves—Washington, DC, and Prince George's County, Maryland—84 percent of the clinic's patients are limited English proficient and 92 percent are Hispanic. Much of the Latino population in the DC metropolitan area is from Central America, Wilson said, adding “It's one of the few places where you can really see the salient characteristics of Central American migration, as opposed to a broader Latino migration or a smaller subset of Mexican migration.” About 40 percent of the clinic's patients are uninsured, and 26 percent are covered under Medicaid. Washington, DC, has an insurance product called the DC Health Care Alliance, which provides an insurance-like product to anyone under 200 percent of the federal poverty level regardless of immigration status, although it does not provide behavioral health care. About 20 percent of the clinic's patients are covered by this program.

The clinic's patients lack access to health care for a variety of reasons, including exclusion from government programs, the Patient Protection and Affordable Care Act enrollment barriers, the complexity of navigating eligibility for mixed-status families, and language access. In particular, many patients are worried about applying for programs given new concerns about their immigration status. “For the enrollment period that started right after the election, every single patient who came in said, ‘Should I really apply? Is it worth it? Am I safe applying?'” she explained.

In the clinic, providers see many conditions caused by lack of preventive health care, including obesity, hypertension, diabetes, HIV infection, and late prenatal care entry. In the area of behavioral health, the clinic sees many cases of depression and other mood disorders, post-traumatic stress disorder, and alcohol-related disorders. For example, rates of post-traumatic stress disorder among Central American refugee patients range from 33 percent to 60 percent. “We have significant unmet need across the region in terms of behavioral health,” said Wilson. “It's more how many therapists can we afford to pay, not what's the need in the community,” she added. In addition, the DC metro area has had an enormous influx of unaccompanied minors, including an estimated 7,000 of the 60,000 children from El Salvador, Guatemala, and Honduras who were detained at the southern border in 2014–2015.

As an example of the ways in which immigration acts as a social determinant of health, Wilson mentioned gender-based violence. The clinic does many screenings for intimate partner violence, resulting in one to two referrals per week. “We see significant immigration fears that prevent women from getting to safety,” she said, adding “we see significant challenges in navigating the complexities of civil concerns and immigration concerns.” For example, taking a child to school “while you're trying to be safe from an abusive partner demands intensive support and can have dramatic effects on our patients,” she explained.

Another example is the association between fear of deportation and HIV risk behaviors among nonpermanent residents. In general, Hispanics in Washington, DC, get tested for HIV infection later than members of other ethnic groups. Homophobia, transphobia, and past traumatic experiences drive economic instability, social instability, and risk behaviors, including substance use, commercial sex work, and depression.

La Clínica del Pueblo works on all the social determinants of health, said Wilson, including social and economic factors and health behaviors. “We look at our patients not just as individuals but as members of communities—and members of communities that are affected by not only policy but also by culture and by history and economics,” she said. As such, the clinic's approach to reducing health disparities includes the following:

• Ensuring access to affordable, culturally competent, and linguistically appropriate health services, including prevention, care, and treatment
• Recognition of the key role of mental health on health outcomes
• Support to reduce barriers to care
• Creating safe spaces in which the Latino immigrant community can critically explore and discuss the effect of immigration on physical and mental health
• Enhancing feelings of belonging and social support, particularly from family, friends, caseworkers, and health care providers
• Community health promotion
• Providing opportunities for social action, including volunteerism and activism

In general, said Wilson, “The community is our patient, not just each individual.” The clinic trains 40 to 60 promotores de salud each year to work in the community. It also seeks to inform patients about advocacy, participation in local issues, and immigration issues, such as language access laws and access to other health services. The clinic has been leading a campaign based on the idea that “no human being is illegal,” she explained.

Immigration and health care are linked, Wilson concluded. “We are not an immigration services organization. We are a health care organization that serves immigrants.… We can't address one without addressing the other,” she said. For that reason, pursuing comprehensive immigration reform is a public health strategy, she said. Wilson concluded:

Looking locally but also looking nationally is a public health imperative. We have to look systemwide and structurally if we're going to have an impact on what happens in the exam room with our patients.

DATA AND POTENTIAL POLICY CHANGE

During the discussion period, the presenters focused on the use of data to drive policy change. Wilson pointed out, for example, that data on whether the DC Health Care Alliance reduces preventable emergency room visits could help make the case for wider access to health insurance:

The more that we can have data that backs up what we see on the ground and policy statements from respected nationwide organizations, the more we can make our case that funding and support for these concepts make a big difference.

Ponce made a similar observation. Could data on increased detection of prediabetes rates as a result of CHIS results, for example, reduce overall health care costs? Though CHIS is expensive, costing $8 million to $10 million per year, it has affected health care, such as increased rates of cancer screening, that could yield major savings, though so far these effects have not been quantified.

In Florida, Castañeda noted, researchers rode along with families as they were trying to access dental coverage under Medicaid for children and discovered that fewer than 20 percent of the dentists in the region were accepting dental Medicaid for children. “That was information that policy makers at the state level weren't aware of,” she said. “Going through the experiences of the family and then trying to portray that to policy makers can be a powerful way to bring up these sorts of issues,” she explained. In this case, both hard data and stories “about how one event can have ripple effects on other parts of people's lives” were important, Castañeda said.