Immigrants make up a significant and growing population of the United States. Since 1965 the foreign-born population has swelled from 9.6 million or 5 percent of the population to 45 million or 14 percent in 2015. Today, about one-quarter of the U.S. population consists of immigrants or the children of immigrants (Pew Research Center, 2015). Given the sizable representation of immigrants in the U.S. population, their health is a major influence on the health of the population as a whole.
The process of immigration and the integration of immigrants into American society intersect with many of the social and economic factors that help determine health, including economic stability, access to health care, education, the impact of the built environment, and social and community context. On average, immigrants are healthier than native-born Americans. Yet, immigrants also are subject to the systematic marginalization and discrimination that often lead to the creation of health disparities. These complex interactions between immigration and health have not been well explored, but they are a significant determinant of differences in health and well-being between population groups in the United States.
To explore the link between immigration and health disparities, the
1 The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop was prepared by the rapporteurs as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.
Roundtable on the Promotion of Health Equity held a workshop in Oakland, California, on November 28, 2017, titled Immigration as a Social Determinant of Health. (Box 1-1 lists the roundtable’s mission and objectives.) The goals of the workshop, explained Winston Wong, medical director for community benefit at Kaiser Permanente, were to:
- Describe why immigrant health is important to the United States.
- Explain how the history of immigration in the United States connects to immigration, economic, and health policies today.
- Discuss the role of immigration as a social determinant of health.
The decision to hold the workshop in California was significant, said Wong. The Bay Area has been a hotbed of immigration issues. Angel Island, just a few miles from downtown Oakland where the workshop was held, was the entry point for immigrants coming from Asia, many of whom were incarcerated before they could even set foot into the United States. San Francisco and the Bay Area were a nexus of Japanese American incarceration during World War II, and they continue to be a center of discussion and debate for immigration issues. Many aspects of immigration “come into play in San Francisco and the Bay Area,” said Wong.
In the final session of the workshop,2 Melissa Simon, vice chair for clinical research in the Department of Obstetrics and Gynecology and professor
2 Although Dr. Simon spoke in the closing session, her remarks are placed here in order to establish context for the workshop.
of obstetrics and gynecology/preventive medicine and medical social sciences at the Northwestern University Feinberg School of Medicine, presented a list of the major topics discussed at the workshop. Her list is presented here as an introduction to the workshop’s scope.
First, the lesson of history is that immigration and integration are continuing to occur despite people’s fears. “It’s moving forward no matter what,” said Simon. Second, health care is a human right, and no human is illegal. Now more than ever, services need to be expanded and supported, she said, despite the existence of stress and uncertainty. Third, immigrants need to know about their legal rights, regardless of their documentation status. Fourth, people who come to health care providers for care have rights by virtue of their being human. Fifth, the widespread misconceptions and misinformation that exist about immigrants and immigration need to be reversed. “We had some very brave people at this workshop sharing their stories. How do we amplify that?” she asked. Sixth, immigrants are not monolithic. On the contrary, they are extremely diverse. For example, being an immigrant does not mean being poor, no more than being a person of color implies poverty. Seventh, data matter. They inform policies for leaders at all levels. Eighth, immigrant and refugee cultures provide their communities with powerful support systems and networks that translate into hope and resilience.
Chapter 2 of this publication provides an overview of the history of immigration policy in the United States, the current state of immigration policy, and the effects of immigration on health and well-being. Also discussed are issues of data disaggregation and data security regarding immigrants. Chapter 3 looks more deeply at immigration as a social determinant of health,3 examining the national, state, and local dimensions of this relationship. Chapter 4 presents the voices of several immigrants, both directly and through the organizations that work with and represent them. Finally, Chapter 5 revisits some of the major themes that arose during the workshop and points to unmet needs in the areas of research, policy, and practice.
3 The social determinants of health are defined as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels” (WHO Commission on the Social Determinants of Health, 2008). Social determinants include access to good schools, availability of reliable transportation, high-quality housing, employment opportunities, and so on.