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Reflections on the Workshop
In the final session of the workshop, two presenters—Hal Yee, chief medical officer for the Los Angeles County Department of Health Services, and Tiffiany Howard, associate professor of political science and director of the Center for Migration, Demography, and Population Studies at the University of Nevada, Las Vegas—along with various members of the Roundtable on the Promotion of Health Equity, briefly commented on the main messages emerging from the workshop and pointed to remaining unmet needs.
GRAPPLING WITH THE COMPLEXITIES OF IMMIGRATION
Immigration is a very complicated subject with many views and many stakeholders, said Yee, and “unfortunately, in some areas, there is not going to be agreement.” Yet, health care providers need to provide care to the patients they see despite the complexities and challenges they may encounter. “Each individual, regardless of immigration status or any other determinant of health, deserves equity of medical care,” he said.
Yee also called attention to the underlying problem of the cost of health care. “In America we spend 17.5 percent of the entire GDP [gross domestic product] on health care,” he observed. As a result, the nation cannot invest what it needs to invest in other areas, even though such investments may prevent health problems that contribute to the cost of health care. “We need to focus more on how we provide the right care at the right time in the right place by the right person, because only by freeing up resources can we invest in all of the social determinants in health,” he said. If health
care were more efficient, more resources could be devoted to alleviating the social issues that lead to many health disparities, including those associated with immigration.
Howard emphasized that immigration as a social determinant of health goes beyond immigration status and encompasses the entire process of immigration. As an example, she mentioned working with Syrian refugees who needed to establish a credit history to secure an apartment. But they had no history of using credit in their home country and did not see the value in doing so. “We don’t think about the nuances that immigrants confront or the challenges that they face when they come here. These cultural barriers are often overlooked, [but they] affect all facets of their existence,” she said.
Roundtable member Uchenna Uchendu pointed out that everyone can do something within their area of influence to help immigrants deal with the complex issues they face. “What can I do in my own space, in my own community? What awareness can I create? What energy can I develop?” she asked. She has written letters to the electric company saying, “This person can’t be without power because there’s an oxygen tank in their home, and you pretty much sign their death warrant if you turn off their power.”
Uchendu recalled the “double battle” that some groups have to undertake because they are immigrants while also dealing with another issue. “In health equity, we talk about the intersection of vulnerabilities,” she explained. For example, immigrants can have mental health disabilities or be dealing with other issues. “Again, it comes back to that connection about the holistic individual,” she noted.
Gillian Barclay called attention to the link between immigration and racism. Both are linked to difficulties in accessing health care, and feelings about immigration can be difficult to separate from racial discrimination, she said. Francisco García made a similar point, raising the issue of the association between immigrant status and poverty. For example, the Afro-Latino diaspora communities and Native American communities are both diverse populations, but they are also relatively poor populations. Therefore, addressing health care also means addressing issues of equity, economic fairness, and justice. “The solution is not always in the doctor’s office. It is in the economic opportunities that we create in our communities,” García said.
UNMET NEEDS
Reflections on the complexity of the issues associated with immigration led several roundtable members to comment on the conversations that need to take place regarding immigration. One involves the basic definition of health equity. Uchendu remarked that health equity means lifting everyone
as a result of taking care of the differences among people while recognizing that some people “are standing so far behind that even equal treatment will always leave them behind.” Melissa Simon said that the metaphor she uses is an apple orchard. For everyone to get an apple from the tree and not settle for a rotten or half-eaten apple from the ground, everyone needs a stool, but some people need a taller stool than others. “That’s the visual I use for teaching about health equity versus equality, which would be the same size stool for everybody,” she explained.
Another is the definition for a social determinant of health. The planning committee approached the topic of immigration from this perspective: 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 effect of the built environment, and social and community context.
Simon also observed that more discussion is needed about what the word determinant actually means. “Determinant can have a negative connotation,” she said, adding that “it can imply that you are destined for this, that if you are an immigrant you are destined for poverty or you are destined to not have any chance or hope or resilience.”
More broadly, said Cara James, the United States needs to have a conversation about the nature of health care. The social determinants of health framework emphasizes the many interconnections between health and other aspects of life, including immigration. Without knowing exactly what health care encompasses, people are talking past each other in policy discussions, she said.
Patricia Baker said that even after immigration is accepted as a strong determinant of health, the question becomes, “Then what?” What policies, practices, and actions need to be taken to produce equitable health care for immigrants? Some of these policies will involve short-term change, some intermediate-term change, and some long-term change. Culture, for example, “cannot be changed overnight, and it is very different in red places and blue places,” she noted.
Octavio Martinez pointed to the need for a cohesive set of core values, including respect for human life. “If we respect each other, then obviously we will respect and give prominence to keeping healthy regardless of what your status may be. If you’re within the borders of the United States, we ought to be looking to each other to take care of each other,” he stated. Treating health care as a right would influence many other ways of looking at things, including the other social determinants of health, he said. The nation spends more than $3 trillion on health care annually, and if some of that money could be spent more effectively to deliver health care to everyone, many people would be healthier than they are today.
Another conversation that needs to be happening, said Uchendu, is
with people who are opposed to immigration and the provision of services to immigrants. “How do you bridge those gaps? How [do we] get everybody on board to see what a difference it could make to them as well?” she asked. Uchendu added, “there is a lot of heart in this country.” People are willing to help others, which is why so many work in health care, emergency services, or other service professions, she stated, adding, “the truth is that the innate human wants to help other people. We can harness and harvest a lot from that.”
James made a similar point in emphasizing the importance of raising awareness of immigration issues among people whose families have not recently immigrated to the United States. Conversations about immigration play out very differently in more and less diverse regions, she noted. In addition, the power of narratives can work against honest and informed conversations, because, she said, “when people get a firm hold on those narratives, it’s hard to get them to hear information contrary to what they believe.”
One of the greatest impediments to these conversations is the amount of misinformation that exists with regard to immigration, said Howard, adding, “the first step is providing quality information.”
Eve Higginbotham recalled the historical dimensions of the immigration issue. During the Civil Rights movement, people hoped and believed that things were going to change, and some things did change. “What was different about the Civil Rights movement that allowed for policy changes? Why were more people in the U.S. population allowed to enter the majority space during that period?” she asked. People do not change their thinking or behavior just because of an increase in awareness. Data are important, Higginbotham observed, but the conversation needs to be framed differently to enlarge the issue.
Several roundtable members emphasized the importance of gathering additional data about specific issues. “If we don’t have the data, then you don’t know what you’re dealing with,” said Uchendu. However, data need to be collected in ways that do not threaten people who are already threatened, she added. Thus, data on immigration should be collected through what she called “the equity lens.”
Refugees, specific immigration groups, and the effects of culture on resiliency are other areas members cited where data gathering needs to be intensified. In its first year in office, for example, the Trump administration cut the number of refugees admitted to the United States to the lowest level since the Refugee Act was passed in 1980. This is a small set of people who come to the United States and enter the health care system, but they have many of the same barriers in terms of language, culture, and other barriers as other immigrants.
Howard said that she would have liked to hear more about Afro-
Latinos who have immigrated to the United States. They face a number of hurdles, including discrimination because of their ancestry and language barriers. She also pointed to the problem of access to nutrient-rich foods in immigrant communities, adding, “when immigrants are relegated to certain neighborhoods and do not have access to quality food, that has implications for their health outcomes.”
CARING FOR THOSE IN THE SHADOWS OF LIFE
Roundtable member Winston Wong cited a quotation from Hubert Humphrey that is engraved on the U.S. Department of Health and Human Services building in Washington, DC, that bears his name: “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy, and handicapped.”
To that quotation, said Wong, “I would add ‘the newest Americans.’” Health care in the United States is characterized by a mentality of scarcity, as if the only ones who can pursue health are those who can afford it. But the new narrative about health care, especially as it relates to immigration, should not be about scarcity, Wong said. “It’s about seeking the productivity and the promise of what America is. It’s about capturing the pursuit of health and all the investments made in people on their journeys to wellness,” he concluded.
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