Several sessions at the workshop emphasized the voices of immigrants, whether directly or indirectly through organizations that serve them. In describing their experiences, these presenters clearly demonstrated the many effects that immigration has on health.
Asian Health Services, a community health center located just a few blocks from where the workshop was held in downtown Oakland, serves 28,000 patients, most of whom are limited English proficient. It provides comprehensive care, including dental care, behavioral health care, and preventive services, in English and 12 Asian languages. It also has a dual advocacy mission to address the structural factors that prevent people from getting the care they deserve. “Health care is only part of your right to have a healthy life,” said Thu Quach, the organization’s director of community health and research. Asian Health Services works in communities not just to ensure that people get access to care but to assert their right to access care. “I myself am an immigrant,” said Quach; “I came here as a refugee from Vietnam at the age of 5 with my family and experienced a lot of that.”
Quach recounted several stories from the clinic that highlight how immigration affects health. The first was of a Chinese patient who came from a small village in China and became HIV positive, after which he was shunned by his community because his HIV status revealed his sexual orientation. He went to New York but could not get care there, and someone said that he should seek out Asian Health Services. He moved to the Bay Area, came to Asian Health Services, and got the care he needed. Quach said that last year he wrote to our staff and said:
Thank you, because at the time I came to you I had almost given up. But you wouldn’t let me give up, you kept pushing and pushing, and finally I got into care. Not only am I healthy but I joined a church choir, I’m singing, I’m part of a network, and I got a job.
The second story involved a teenage Cambodian girl who came to the clinic where Asian Health Services provided confidential care. There, the clinic’s providers saw patterns coming together that eventually led to the uncovering of a commercial sexual exploitation operation in Oakland.
The third story involved a Vietnamese detainee who had committed a crime when he was a minor, had been tried as an adult, and served 20-plus years in prison. He was released and started a new family, but then he was detained by Immigration and Customs Enforcement (ICE). “He was the sole breadwinner, and his wife was pregnant and about to deliver. What
happens when you take away economic opportunity not just for that one individual but for the entire family?” Quach asked.
Finally, she mentioned environmental justice. When immigrants arrive, they often lack choices of where to live and have to move to highly polluted areas. “They are all factors that affect people’s health,” she explained.
From its founding in 1974, Asian Health Services has recognized the intersection of immigration with health. “It’s nice to see the science finally catching up with us, because community health centers have always recognized that social factors impact health,” said Quach. Asian Americans have faced health disparities that go unrecognized, in part because they struggle with the modern minority myth that Asian Americans do well in school. But the myth obscures hidden disparities. Asian American populations consist of more than 50 ethnic groups and speak than more 100 languages. “You don’t see the disparities that exist within certain groups because it’s being masked,” she said.
Asian Health Services is staffed by people from the community, which is important, reported Quach, because “those who are closest to the problems are often closest to the solutions.” Health care providers are on the front lines of immigration issues, and they need to be able to take stories to higher levels and organize for change. Also, asking about immigration status in a clinic generally requires a relationship between provider and patient, because it is not like asking other questions. “There are so many stories behind it,” she added.
Immigration status is a politically driven issue, Quach observed. She came to the United States from Vietnam with her family, where she received refugee status and eventually became a lawful permanent resident. That status entitled her to public assistance that she would not have received with a different immigration status. “What that sets up is the dichotomy of the good versus the bad immigrant,” that some immigrants are more deserving than others, she said, adding that “we need to push back on that framing.” She asked how her experience was different than that of a child who needs to leave Latin America to survive. “Yet, the statuses given to each of us [establish] barriers, both in terms of political barriers and social barriers,” she explained.
She raised three issues for the Asian American immigrant community. First, undocumented status is usually associated with Latinos, but “there are actually a lot of Asian Americans who are undocumented as well,” Quach said. These undocumented immigrants are afraid not only of persecution but of the stigma they would receive from their own community if their status were known. For example, Asian Americans have a low rate of applying for DACA. “When we talk to those individuals, they have many reasons—not fear that they’re going to now be known by the government, but they’re afraid they’ll be shamed in their churches and such,” she noted.
The second issue she raised involves the issue of public charge. The law requires that decisions about naturalization consider whether someone is going to rely on public benefits, including cash assistance and long-term care. If it is determined that a person will be a public charge, that person will not be allowed to enter. If they are allowed to enter, for the first 5 years they are not allowed to use public benefits. A leaked executive order that was not enacted expressed the intention to investigate immigrants who were using public benefits. “Even though that has not been signed, it has had a chilling effect among our patients,” said Quach. “They’re afraid to sign up for things like food stamps. [But] by not seeking health care, by not having access to healthy food, that is going to affect not just them but also their family members,” she said.
The third issue she raised involved detention deportation. Individuals who have served their time in prison and have been released are being detained because they are not citizens, said Quach, adding:
We are hearing stories of ICE rounding up Cambodians and Vietnamese and detaining them and working with their country to try to deport them. And these are not people who committed a recent crime. It’s individuals who have gone into prison, have served their time, have been paroled, and have been released. Some have started families again and are now being ripped from their families. You can imagine all the different health implications that go with that.
One missing voice in the immigration debate is the veteran’s voice, said Octavio Hinojosa, the Veterans for New Americans Coordinator on behalf of the National Immigration Forum. “We are a nation of immigrants,” he said, and “so are our armed forces.” In each major conflict in the nation’s history, immigrants have played an integral role in the military, whether the Revolutionary War, the Civil War, World War I, World War II, or the Iraq and Afghanistan conflicts. Today, immigrants continue to add to the military’s cultural competency in global operations.
However, parts of the military are still not welcoming to immigrants, Hinojosa observed, and this stance is reflected in recent policy changes at the Pentagon. One issue is enlistment and recruitment. Currently, any legal permanent resident can go to any recruiting offices and enlist and he or she will be allowed to serve. In addition, after 9/11 President Bush signed an executive order allowing for expedited naturalization, “which basically meant that if I got my green card today and went to the recruiter’s office this afternoon and I enlisted, then within a year I should have my citizenship by serving in the military,” Hinojosa said. Of the 511,000 immigrant veterans in the United States, 84 percent have become naturalized citizens. The other
16 percent have not, representing approximately 98,000 veterans, with approximately one-third of those living in California.
The expedited nationalization policy was rescinded 1 month before the workshop took place (October 2017). Now, legal permanent residents are required to go through additional screenings, which will delay their naturalization by 2 years or more. Also, the U.S. Army Reserve and National Guard are no longer allowing legal permanent residents to enlist in the reserves as a way of obtaining citizenship. Yet, all five branches of the military are struggling with recruitment, Hinojosa observed, leading them to offer increasing enlistment bonuses and higher benefits. “Instead of looking at the potential talent in the population of undocumented youth, such as the Dreamers, we’re missing out on a great opportunity to allow them to serve in exchange for residency and eventually citizenship,” he explained.
It is not known if the health of immigration veterans is better or worse than average, though that would be useful information to have, Hinojosa said. He reiterated that the immigration population tends to be healthier than the native-born population and that, according to an analysis from the Center for Naval Analysis in 2015, less than 20 percent of the 18- to 29-year-old population in the United States is qualified to serve because of health issues, predominantly obesity. “Obesity needs to be seen as a national security threat,” Hinojosa noted.
Following the failed effort to pass immigration reform in 2014, the National Immigration Forum has been seeking to engage with conservative constituencies. Through an initiative called BBB, for Bibles, Badges, and Businesses, it has been seeking to engage the evangelical community, the law enforcement community, and the business community, “and by doing that we have made tremendous headway in changing hearts and minds when it comes to immigration,” Hinojosa said.
The other issue Hinojosa cited is that of deported veterans. Legal permanent residents who have served in the military and commit a crime are being automatically put into deportation proceedings. The government is not tracking the number of deported residents, but guestimates range up to 3,000 or more. These veterans qualify for benefits from the Veterans Health Administration, but they cannot access those benefits because the U.S. Department of Veterans Affairs is not in their home countries. They are not being allowed to return to the United States until they have passed away, after which they have a right to be buried in a U.S. cemetery. “Think about those types of injustices,” Hinojosa said.
When veterans are deported back to their countries of origin, they are at the mercy of their home country’s health system. They may not even speak the language of their home country, and they may not be able to get the health care they need in that country, even in countries with universal health care. “If you deport a veteran who does not have the job skills or
the language skills to readjust to Mexico City life, then he’s basically out of luck,” noted Hinojosa.
One recommendation Hinojosa made is for medical professionals to go to the countries where deported veterans are living and provide them with the health screening and medications that they need. But to achieve such a goal, he stated:
We need to raise awareness that we have men and women who have served in uniform, who have risked their lives and sometimes have even earned the Purple Heart, and unfortunately are now living in exile.
Hinojosa was not optimistic about making progress with the Congress as it existed at the time of the workshop. The fault was the 1996 immigration laws, which increased the number of crimes that are triggers for automatic deportation without the possibility of judicial discretion. The states are more active. For example, the governor and legislature of California have pardoned several deported veterans, “but now we have to deal with the federal laws.” Many high-ranking people in the military understand the issue, said Hinojosa, and want to do something about it. “They understand and appreciate that they fought alongside immigrants and they’re willing to go bat for them. I find that reassuring,” Hinojosa concluded.
Alejandra Baltazar-Molina, who came to the United States as a child from Mexico City, works as a community health advisor at a community health center in Tucson, Arizona, in an area with a largely Mexican population. “I love what I do,” she said. She added that “it’s amazing how one person can change the life and health care of a person who doesn’t know that I can ask for help even though I’m undocumented.”
Baltazar-Molina has been one of seven young people represented in the project DACAmented Voices in Healthcare (Gómez and Castañeda, 2018). The organization arose out of the interest of Sofia Gómez in state-level immigration policy, which in Arizona has turned strongly against immigrant communities. To learn how these policies were affecting the immigrant community, she turned to youth that qualified for DACA, “because who else can speak to this but those who live that experience?” she asked. DACAmented Voices in Healthcare provides a platform for discussion and identification of health care experiences and needs. DACA youth addressed their experiences in health care using PhotoVoice, which combines photography and prose to enable people to tell their own story.1 PhotoVoice additionally enabled the youth to have critical conversations with each other and with policy makers
at the local level. “It provides a flashlight in a very dark corner, because we have no idea of the lived experiences of immigration communities in Arizona,” said Gómez.
Each of the seven youth in DACAmented Voices in Healthcare was unique, yet they had a collective voice in what they wanted to recommend, Gómez observed. They identified health literacy, navigating the health care system, and cost of care as major barriers. They also identified resiliency and strength in their community. Gómez said that “I always compared the people to the desert. It’s a harsh environment, but there’s still life and beauty in it.” However, some issues she did not expect, such as those associated with the undocumented lesbian, gay, bisexual, transgender, and questioning population. “The process became the product for me, because as the project unfolded I learned from them,” she said.
Gómez noted that health care providers might miss an opportunity to address health care needs if they do not take into account their patients’ immigration status. The youth in her project felt that providers should consider this, because otherwise how can they understand their patients’ needs? “What if I come from a mixed-status family and my dad just got deported or is in detention? Or I don’t have any income because of my immigration status?” she asked. Gómez observed that is important for researchers to include the voices of community members in developing their projects. People from the community, including young people, want to be more than just token representatives on an advisory board. They want to be actively engaged in defining what is needed and how those needs should be met. “That’s definitely a lesson I heard loud and clear: include the youth voices in health research and policy development,” she said.
Baltazar-Molina said that she has struggled at times as her parents have worked hard to provide for their family. Being part of DACAmented Voices in Healthcare taught her that she was not alone. “Being part of this project was a break in my life,” she said, adding, “we were able to open up and say, ‘This is me, this is my story, and it’s okay to talk about it.’” The voices and images captured through the project also have broader applicability, she said. “This is our struggle as immigrants. . . . Health care is a right that everyone should have no matter their immigration status,” she explained.
Baltazar-Molina pointed to the need for continued advocacy for immigration reform and health care for all. Immigrant youth can help make this case by working with public health departments and local community organizations. She explained that “We wanted to be given a seat and be able to say, ‘This is what our community needs, because we’re the ones who are going through that struggle.’” She advocated for greater training for health care workers and for mental health clinicians who are bilingual and bicultural, because “we need to relate to someone who’s able to speak our own language—someone who can really understand what you’re say-
ing instead of going from a translator who might not be able say how you really feel,” she concluded.
Emmanuel Cordova,2 a medical student at the University of California, Los Angeles, David Geffen School of Medicine came to the United States from Mexico when he was 4 years old because his mother was suffering domestic abuse and wanted a better life for her family. Cordova spent much of his childhood in Chicago as an undocumented immigrant where he experienced firsthand the social determinants of health associated with immigration. His family’s biggest fear was not deportation, he said, but not having health insurance or access to health care. Once when he was 8 his mother had an aneurism and they had to drive 30 minutes to a public hospital for her to get care. After they waited their turn at the emergency department, the doctor told him that no Spanish speaker was available, so Cordova had to act as a translator for his mother and the doctor. “Through that moment of chaos there came clarity,” he said; “I realized that I wanted to be a doctor so I wouldn’t have to rely on a child to deliver culturally and linguistically appropriate care.”
Watching his mother work 12-hour shifts and barely make minimum wage taught him about resiliency, he said, adding, “I learned what it means to have a hard work ethic and to provide for your family despite all the obstacles.” He also learned the value of community. “There was a lot of social cohesion and social capital that helped us get accustomed to the United States,” he noted.
Cordova said that he always loved to learn and took challenging classes in high school. But as an undocumented immigrant he was not eligible for financial aid to attend college. However, a high school counselor was dedicated to getting him into college. “With her help, I was able to go to the University of Illinois, Chicago,” he said, although to pay his college fees he had to work 20 hours a week at a fast-food restaurant. “Be nice to people who serve you food,” he said. “They’re human beings, too.”
After 2 years at the University of Illinois, budget cuts eliminated his scholarship, but his advisor at the university told him that top-tier universities offered scholarships to students like him, and he was able to transfer to the University of Pennsylvania. Getting his degree there was a moment of great pride and accomplishment, but he was also frustrated by how few students like him got that opportunity. “There were a few dozen of us in
2 Although Emmanuel Cordova spoke on a different panel, his comments are presented here for continuity of the topic of immigrant voices.
that school who received aid, but there were thousands of undocumented immigrants who didn’t get the privilege that I did,” he noted.
After college, he worked for 2 years with Melissa Simon at Northwestern University as a research assistant. One of the highlights of that experience, he said, was a meeting where members of the community were invited to the university to talk with top-level administrators about their concerns. “To see community members sitting next to people who are at the top of their field was breathtaking,” he explained. “I’m very thankful for all the things I went through,” he said, “because they gave me a lot of resiliency. They made me realize the power that our communities have, not only in overcoming social obstacles but in terms of the power and influence and wisdom they have,” he said.
Now a legal resident, Cordova emphasized the diversity of the undocumented population. Immigrants come from many different places and have many different statuses. Health care providers need to be aware that these differences exist, he said, and not assume that all immigrants have the same backgrounds or experiences. Inequities magnify the problems that communities face in terms of health outcomes, he said. But the power and resiliency communities have is often overlooked, and this resiliency could be used to leverage sustainable interventions and policy change.
He also emphasized the importance of communication in doing research on the immigration population. “It isn’t enough to reach out to a community organization and expect them to give back the resources you need,” he said. Rather, he said,
You need to invest a lot of time and effort and passion in making sustainable relationships with the community members. A lot of community members are socially conflicted by being undocumented and are going to be secretive unless they know that they can trust somebody.
To gain that trust, researchers need to treat community members with dignity and not as research subjects, he said, adding “Understanding their life stories is probably the best way to do that. Before you even get to the research, ask them where they came from, their life stories, and what they want out of this research.”
Grassroots efforts have great potential to change policy, he concluded. “DACA was born out of that movement, out of the civil disobedience people did, basically putting their lives on hold to make sure that DACA passed,” he concluded.
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