AN OVERVIEW OF IMMIGRATION TRENDS AND IMMIGRANT HEALTH STATUS IN THE UNITED STATES
Sana Loue, J.D., Ph.D., M.P.H. Case Western Reserve University School of Medicine OHSU Global Health Symposium Portland, Oregon March 17, 2007
“Keep ancient lands, your storied pomp!" cries she With silent lips. "Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!" Emma Lazarus
STATISTICS
As of 2004, 34.8 million foreign-born persons residing in the U.S. (2000 Census, 2004
Yearbook of Immigrant Statistics)
Immigrants account for 12% of the U.S. population At least 500,000 Mexicans have crossed the border annually, illegally, since 2000
(March 2005 Current Population Survey, conducted by US Bureau of Labor Statistics and Census Bureau)
ENTRY MECHANISMS
As permanent/conditional resident through qualifying family member or qualifying employment On temporary basis, e.g., student, tourist, journalist Asylum, refugees Undocumented
EXCLUSION CRITERIA
Health-related grounds: HIV, substance use, active tuberculosis, STIs, lack of specified immunizations, “likely to become a public charge” Criminal grounds Moral grounds: prostitution
PERCENT DISTRIBUTION OF FOREIGN BORN BY WORLD REGION OF BIRTH: 2003
Other Regions 8.0%
Europe 13.7% Latin America 53.3%
Asia 25.0%
Source: Current Population Survey, Annual Social and Economic Supplement 2003
Age Distribution by Sex and Nativity: 2003
(In Percent)
Foreign Born
Male Female
Age
85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4
Native
Male Female
8
6
4
2
0 Percent
2
4
6
8
8
6
4
2
0 Percent
2
4
6
8
Source: Current Population Survey, Annual Social and Economic Supplement, 2003
DEMOGRAPHICS
Less than 9% of foreign born under the age of 18, compared with 27.9% of native-born population 21.5% of foreign-born have less than 9th grade education, compared with 4.1% of native-born population
• 37% of white immigrant whites and 21% of black immigrants have hs diploma, compared with 26% and 13% of native-born, respectively • 43% of Hispanic immigrants have hs diploma compared with 68% of US-born Hispanics
DEMOGRAPHICS 2.
27.2% have BS/BA, same proportion as native-born 22.2% of immigrants settle in northeast, 11.3% in Midwest, 29.2% in southern states, 37.3% in western states; almost ½ settle in metropolitan areas Immigrants more likely to be living in poverty, more likely to be married, and more likely to have larger family than U.S.-born counterparts
• Latin Americans and Asians more likely to live in western states
IMMIGRANT POPULATION IN TRI-COUNTY AREA
40 30 20 10 0 2 Africa 7 Other Asia 20 36 35
Africa
Latin America
Other
Europe
Asia
CHARACTERISTICS OF IMMIGRANT POPULATION, PORTLAND
108% increase in immigrant population 19902000 11% of population is foreign-born, compared to 9% in Oregon Foreign-born account for 13% of city population Almost one-third arrived after 1995; 53% arrived since 1990 61% have income < $25,000/year 26% have bachelor’s degree Spanish is most frequently spoken language, followed by Russian, Vietnamese, Chinese, Slavic languages Low naturalization levels
• A significant proportion speak English “less than well.”
FRAMEWORK: Factors Affecting Immigrants’ Health in U.S.
Pre-migration Peri-migration Post-migration
PRE-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: TUBERCULOSIS
1997: 39% of all cases of tuberculosis occurred in foreignborn individuals (Centers for Disease Control and Prevention, 1998). 1985-1992: among all incident TB cases nationwide number of cases among foreign-born persons in the U.S. accounted for 60% of the total increase in the number of incident US cases (Cantwell, Snider, Cauthen, and Onorato, 1994). The median interval from the time of immigration to the reporting of foreign-born cases in 1992 was 3 years; 30% of the cases were reported within one year of immigration. 1998-2001: annual number of TB cases among African immigrants and refugees in Seattle and King County increased almost three-fold compared to the period from 1993 to 1997 (Anon., 2002). Almost one-half of the individuals had extrapulmonary TB.
PRE-IMMIGRATION AND TUBERCULOSIS 2.
1985-1994: Of the 3,364 cases of TB among Asians in Los Angeles County, California, 98% were immigrants (Makinodan, Liu, Yuno, Knowles, Davidson, and Harada, 1999). The TB case rate per 100,000 foreign-born Asians living in Los Angeles County was 162.1, compared to 2.6 per 100,000 among U.S.-born Asians in the same county. 1992-94: Minneapolis, despite initial TB screening by U.S.authorized physicians in India prior to immigration to the U.S., 51% of the chest radiographs of Tibetan immigrants taken in Minneapolis were abnormal (Truong, Hedemark, Mickman, Mosher, Dietrich, and Lowry, 1997). A comparison with the results from the chest radiograph evaluations conducted in India indicated that 79% of the Tibetans had unchanged readings and 21% showed evidence of potentially progressive disease.
PRE-IMMIGRATION AND TUBERCULOSIS 3.
1995: of all tuberculosis cases occurring in Broward, Dade, and Palm Beach Counties in Florida, 49% of the 629 individuals with reported tuberculosis had been born in 40 countries. Of those individuals with a known date of arrival in the U.S., 68% had been in the U.S. for more than five years; overseas immigrant screening for tuberculosis had identified only three cases (Granich, Zuber, McMillan et al., 1998). A large number of persons entering the U.S., including most nonimmigrants, such as tourists and students, are not subject to screening procedures.
PRE-IMMIGRATION AND TUBERCULOSIS 4.
A recent study of culture-positive tuberculosis patients in the Fort Worth-Dallas, Texas metroplex, the ninth largest metropolitan area in the United States, found that a greater proportion of nonimmigrants had multi-drug resistant TB and were HIV-positive, compared to those with permanent residence and those who were undocumented (Weis, Moonan,
Pogoda, Turk, King, Freeman-Thompson, and Burgess, 2001).
Screening procedures utilized currently are less effective than is desired and the requisite follow-up of immigrants entering the U.S. who are known to be infected with TB is less than adequate. Legislation that increases the fear of detection by immigration authorities may exacerbate delays in seeking care (Asch, Leake, and Gelberg, 1994).
PRE-IMMIGRATION AND TUBERCULOSIS 5.
Misconceptions about the nature of the disease and its treatment may also play a role
• Viewed as highly contagious, caused by environmental exposures, such as cigarettes and alcohol, unsanitary conditions, wet clothing, and bacteria and viruses; imbalances of the body occasioned by overwork, poor nutrition, respiratory illness, worrying and family problems, and family inheritance; and contagion from an infected person through touch, the sharing of utensils, or airborne spread (Yamada, Caballero, Matsunaga, Agustin, and
Magana, 1999).
• Can be treated through modern medical attention, traditional medicines, improved sanitation and air, smoking cessation, and the correction of imbalances of the body through proper rest, exercise, discipline, diet, and a positive outlook.
PERI-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S. Traumatic injury Hypothermia Heat stroke Injuries associated with trafficking Communicable disease
• Golden Venture • Disease contracted in home country • Higher rates childhood disease, lower rates vaccinations
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.
Fewer bed-disability days compared with US-born Hispanic immigrants more likely than others to experience serious psychological distress; immigrants less likely than US-born to experience serious psychological distress US-born almost 50% more likely than immigrant counterparts to be obese Prevalence of smoking, hypertension, cardiovascular disease higher among US-born compared with immigrants
• Prevalence of obesity among Hispanic immigrants increases with increased length of residence in US
• Proportion of Hispanic immigrants with cardiovascular disease, hypertension, increases with increased length of residence in US
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: CANCER
Incidence of breast, colorectal, and stomach cancers in immigrant populations to the United States tends to converge towards the rates seen in the United States and away from those in their countries of origin. • Breast cancer incidence rates,1983-1987 among Chinese, Filipino, and Japanese women under the age of 55 in the immigrating generation were higher than in their native countries and converged towards the even higher rates of similarly aged women in the San Francisco, Oakland, Los Angeles, and Oahu areas (Ziegler
et al. 1993).
• 1986-1990, cancer mortality in Chinese immigrants to NYC, U.S.-born whites, and Chinese in Tianjin: standardized proportion breast cancer mortality ratio for the NYC Chinese was intermediate between the lower rate among Chinese in Tianjin and the higher rate among U.S.-born whites (Stellman and Wang, 1994).
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: CANCER 2.
Significant gaps in health screening utilization by immigrants
• Women who had immigrated to the US during previous 10 years least likely to have had a mammogram within the previous 2 yrs or a Pap test within the previous 3 yrs (Swan, Breen, Coates, Rimer, and Lee, 2003). • Among men and women, recent immigrants least likely to have had a fecal occult blood test or endoscopy within recommended screening interval.
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: CANCER 3.
Study of 148 foreign-born women of Latino ethnicities living in or around Washington, D.C.: 93% reported ever having had a Pap smear, 42% had one in year prior to study; 71% had one in the 3 yrs immediately preceding the study; 24% had not followed screening recommendations for cervical cancer (Fernandez, Tortolero-Luna, and Gold, 1998).
• Women over the age of 40: 62% had ever had a mammogram; 33% had followed the screening recommendations for their age • Embarrassment about the exam, fear of the test itself, fear of detecting cancer, cost, and the absence of any symptoms that they believed would indicate the existence of cancer. • Women in US 5 to 9 years more likely than recent immigrants to have complied with screening recommendations. (Fernandez,
Tortolero-Luna, and Gold, 1998).
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: MENTAL HEALTH AND SUBSTANCE USE
Posttraumatic distress syndrome Depression
• Study 1,789 Latinos in rural and urban counties in the Sacramento area: prevalence of depression highest among immigrants and higher still among least acculturated (Gonzalez,
• Immigrants from Mexico may be at higher risk of suicide than their counterparts in Mexico, but at lower risk than their counterparts born in US (Sorenson and Shen, 1996).
Haan, and Hinton, 2001).
Substance use
Tendency of immigrants to settle in ethnic enclaves in large cities, close to other immigrants, family, friends, may be preventive factor, reducing social isolation, promoting contact (Shen and Sorenson, 1998).
• Particular problem among immigrants in urban areas • Longer residence in U.S., higher levels of immigrant youth acculturation to U.S. culture, and parental ascription to traditional gender roles for their children may increase the risk of substance use among immigrant youth
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: MENTAL HEALTH SERVICE UTILIZATION
3,012 randomly sampled Mexican Americans in urban, small town, and rural areas of Fresno County
• Only 15.4% of immigrants found to have a mental disorder had utilized mental health services, compared to 37.5% of U.S.-born study participants with diagnosis (Vega, Kolody,
Aguilar-Gaxiola, and Catalano, 1999).
• Proportionately more mental health services were utilized by immigrants living in urban areas as compared to rural areas.
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: BARRIERS TO CARE
Lack of insurance coverage Language Cultural beliefs about disease, illness, and treatment Xenophobia, racism Lack of legal protections
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: HEALTH INSURANCE COVERAGE AMONG IMMIGRANTS
33% have no health insurance, compared to 13% of nativeborn (Migration Policy Institute, 2004) • Of the 67% with health insurance, 78% covered by private plans, remainder by government plans • Foreign-born individuals more likely to be in service jobs than US-born (23.3% vs. 14.9%) Most permanent residents required to have status for 5 years before can access publicly insured programs Temporary immigrants, undocumented-ineligible for publicly funded programs Longer-term immigrants more likely to be insured • Almost ½ of immigrants in US <10 years are uninsured More likely than US-born to be without usual source of care
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: IMMIGRANTS AND GOVERNMENT-FUNDED INSURANCE
Qualified:
• If entered US before 8/22/1996 as lawful permanent resident; refugees, asylee, withholding of deportation, conditional entry, paroled into US for at least 1 yr; Cuban-Haitian entrant; battered spouse or child meeting specified requirements • If entered on or after 8/22/96 as refugees, asylee, withholding of deportation, conditional entry, paroled into US for at least 1 yr; Cuban-Haitian entrant; battered spouse or child meeting specified requirements, certain veterans and specified family members
Not qualified: everyone else, with certain exceptions for specified programs
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: GOVERNMENTFUNDED HEALTH INSURANCE ELIGIBILITY
All groups eligible for emergency Medicaid Full-scope Medicaid:
State Children’s Health Insurance Program (SCHIP):
• Qualified immigrants • Victims of trafficking and derivative beneficiaries
• Qualified immigrants • Immigrants receiving SSI on 8/22/96 in states that linked Medicaid to SSI eligibility • Certain American Indians born abroad • Victims of trafficking and derivative beneficiaries
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: GOVERNMENTFUNDED HEALTH INSURANCE ELIGIBILITY
Medicare “free” Part A (hospitalization) • Qualified immigrants • Victim of trafficking and derivative beneficiaries Premium “buy-in” Medicare • Lawful permanent residents who have resided continuously in US for at least 5 years
POST-IMMIGRATION AND HEALTH OF IMMIGRANTS IN U.S.: STATE-FUNDED HEALTH INSURANCE ELIGIBILITY
Varies by state • Most commonly covered: prenatal care, children, disabled seniors, trafficked and/or abused persons California: prenatal care, long-term care, breast and cervical cancer treatment available regardless of immigration status
CASE STUDY: TRAFFICKING 1.
Forced labor prevalent in 5 sectors of U.S. economy: prostitution and sex services, domestic service, agriculture, factory work, restaurant and hotel work Exists in at least 90 cities in U.S. 2000-2005: involved 19,254 men, women, and children Forced labor operations concentrated in California, Florida, Texas, and New York Largest concentrations of survivors of trafficking in California, Oklahoma, Texas, New York 2002: majority survivors receiving federal assistance resided in Texas, Florida, California Trafficked individuals from 39 countries
CASE STUDY: TRAFFICKING 2. PRE-IMMIGRATION FACTORS AND HEALTH
Religious beliefs Gender roles Poverty Lack of access to care and information
CASE STUDY: TRAFFICKING 3. PERI-IMMIGRATION AND HEALTH
Traumatic injury: rape, violent injury Infectious disease: HIV, STIs Mental health: Post traumatic stress disorder
CASE STUDY: TRAFFICKING 4. POST-IMMIGRATION AND HEALTH
Traumatic injury: rape, other violent injury Infectious disease: HIV, STIs, HAV, HBV, HCV, TB Mental health: Post traumatic stress disorder, substance use OBGYN: Unwanted pregnancy and/or abortion; involuntary sterilization Occupational injury: falls, injury due to repetitive motion
CHALLENGES FOR HEALTH DEPARTMENTS
Identification of hidden populations Development of culturally and linguistically appropriate outreach efforts to promote screening Development of culturally and linguistically appropriate treatment programs Protection of immigrant clients Public education Avoidance of stigmatization and scapegoating Advocacy for improved screening of all travelers
CHALLENGES FOR HEALTH NONPROFIT ORGANIZATIONS
Identification of hidden populations Development of culturally and linguistically appropriate outreach efforts to provide services Development of culturally and linguistically appropriate referral and service programs Protection of immigrant clients Public education Avoidance of stigmatization and scapegoating Advocacy for clients
STRATEGIES FOR DEVELOPMENT OF TRUST
Community advisory boards Identification and collaboration with gatekeepers and formal and informal leaders Strict confidentiality Linguistically matched staff and volunteers Work in, with, and for the communities Use an empowerment model
EXAMPLE OF COMMUNITY-BASED PROGRAM
Boriquen Family Health Center in Miami, Florida
• Serves a large clientele of HIV-positive Latino MSM; 60% of men enrolled in HIV care are from Cuba and Puerto Rico, speaking mostly Spanish and 30% from Haiti, speaking primarily Creole • Five-step process designed to foster a nonjudgmental environment and support clients in accessing and remaining in care:
develop trust; educate; provide HIV counseling and testing; use peers to lead outreach efforts, build relationships with potential clients and provide support to men who come in for counseling and testing; follow up with clients