The Intersection of Racism, Immigration, and Child Health

Abstract

Health professionals who care for children will find a thoughtful and hands-on resource to address racism and race-related issues in their practices in this essay collection. Leading experts from across disciplines frame the issues and provide practical information on prevention, intervention, and anticipatory guidance. Each chapter is grounded in the recommendations outlined in the American Academy of Pediatrics (AAP) policy statement “The Impact of Racism on Child and Adolescent Health.” The AAP is committed to reducing the ongoing costs and burden of racism to children, the health care system, and society—this book is an important contribution to that effort and ongoing conversation. Available for purchase at https://www.aap.org/Untangling-the-Thread-of-Racism-A-Primer-for-Pediatric-Health-Professionals-Paperback

Full text

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 10
The Intersection of Racism, Immigration,
and Child Health
Diana Montoya-Williams, MD, MSHP; Julie M. Linton, MD;
and Olanrewaju Falusi, MD, MEd
Introduction
Immigration is a critical aspect of life and society in the United States. Factors such
as one’s nativity (ie, where one is born), the migration journey, and one’s immigration
status are crucial social determinants of health that affect legal, logistic, cultural, and
language access to health insurance and health care. This differential access creates
health inequities rooted in local, state, and federal immigration policies and practices.1
This chapter defines terms needed to understand relationships between immigration,
racism, and child health; provides an overview of how immigration policies contribute
to racially founded child health inequities; and offers recommendations to mitigate
structural racism and discrimination against immigrant children and families.
Current and Historical Foundational Concepts
In 2019, nearly 45 million immigrants were living in the United States, or 13.7% of the
population. Children who were born outside the country or who have at least one par-
ent who was born outside the country currently represent 1 in 4 US children.2 Attitudes
toward immigrants and, by extension, immigration policies contribute to structural dis-
crimination through racism, colorism, xenophobia, nativism, or religious discrimination
(Box 10–1). Discriminatory attitudes, policies, and practices affect access to quality care
and, ultimately, the health and well-being of immigrant children.
The history of US immigration policy embodies structural racism, colorism, and
xenophobia (Table 10–1). The first US immigration law, the Naturalization Act of 1790,
provided that “free white persons” living in the United States for at least 2 years were
eligible for citizenship,3 racializing US immigration policy from the outset. Designation
of “un-desirable” immigrants based on national origin began in 1875, targeting Chinese
laborers, people involved in the criminal justice system, and commercial sex workers.4
Inequitable policies persisted throughout the 20th century. The 1921 Emergency Quota
Act deliberately favored immigrants from northwestern Europe,4 and in the 1960s,
Cuban refugees, many of whom were wealthy, well educated, and light skinned, received
preferential access to lawful status.3,5 In contrast, after 1965, with the termination of the
temporary Bracero Agreement labor program and new policies capping the number of
permanent resident visas, paths to legal immigration and residence were curtailed or
eliminated for those who had or wished to emigrate from Central America. As a result,
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Part 2, Section 1 Intersections of Racism and Health for Children and Adolescents, Population-Specific Issues
the number of undocumented Mexican immigrants rose.6 Starting in 2017, federal
policies, including the Muslim ban (Executive Order 13769), the zero-tolerance policy
(Executive Order 13841), termination of the Deferred Action for Childhood Arrivals
program, and the public charge regulation, disproportionately harmed families from
Central America, Africa, and the Middle East, most of whom are people of color.7
Further, immigration policy research has inadequately examined the effect of structural
racism on immigrants’ health because race and ethnicity are not recorded by federal
immigration administrations and are often conflated.8 This inadequacy is exemplified by
the policies and practices leading to family separation. Historically, the discriminatory
quotas in 1921 provided no exemptions for people trying to reunite with family members
already residing within the United States. In addition, the 1924 National Origins Quota
Act (Table 10–1) exempted only immediate family members of US citizens, preventing
many extended or multigenerational refugee families, such as Armenian and Jewish peo-
ple, from reuniting.9 Recently, during the execution of the zero-tolerance policy in 2018,
Box 10–1.
Foundational Concepts
Racism
Systematic structuring of opportunity and application of value in favor of some
races over others, with an understanding that race is a socially constructed rep-
resentation of groups of people who share physical or social attributes
Colorism
Discriminatory practices that show preference for lighter skin tones, straight
hair, and more Eurocentric facial features
Xenophobia
Prejudice against or fear of people from other countries
Nativism
Policies that demonstrate protection of or favor for native inhabitants rather
than immigrants
Religious Discrimination
Discriminatory practices against an individual’s or group’s religious beliefs and
practices and/or their request for accommodations of their religious beliefs and
practices
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The Intersection of Racism, Immigration, and Child Health 65
Chapter 10
the sentinel family-separation case (the Ms. L v ICE case) involved a mother and daugh-
ter from the Democratic Republic of the Congo.10 However, national discourse underem-
phasized the role of structural racism in the design and execution of this policy.
Policies of exclusion have also incorporated public health conditions and experiences
that have disproportionately affected communities of color, contributing to structural
racism. In 1891, the federal government began requiring medical officers from the Public
Health Service to exclude immigrants with infectious diseases and chronic conditions,
including serious mental illnesses, intellectual disabilities, and epilepsy.11 On Ellis
Island, mass examinations disproportionately excluded immigrants from Asia and
Central America.11 Recently, in 2019, the federal administration broadened the defini-
tion of a public charge to include people who have used anti-poverty programs such as
Medicaid, the Supplemental Nutrition Assistance Program, and public housing.12 This
rule was reversed in 2021; however, its chilling effect had already triggered decreased
enrollment in federal benefit programs.13 By restricting participation in public programs
designed to keep people healthy, expansion of the public charge rule codified limita-
tions on one’s ability to reach optimal health and financial security. It also targeted
immigrants more likely to experience poverty, disproportionately and structurally
discriminating against communities of color.
Immigration Enforcement and Racism
Despite the discriminatory redefinition of who qualifies for admission into the
United States, the rates and diversity of immigration have risen significantly since the
Table 10–1. A Select Timeline of Key Policies Highlighting the Intersection of
Racism and Immigration
Year Act Description
1790 Naturalization Act of 1790 “Free white persons” living in
the United States for at least 2
years were eligible for
citizenship
1798 Alien and Sedition Acts Authorized the president to
deport immigrants without
citizenship when deemed
“dangerous to the peace and
safety of the United States”
1882 Chinese Exclusion Act Banned immigration of Chinese
laborers, prevented
naturalization of and permitted
removal of Chinese immigrants
Immigration Act of 1882
(continued on next page)
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Table 10–1 (continued)
Year Act Description
1921 Emergency Quota Act Placed first numerical cap on
admissions that was based on
nationality
1924 National Origins Quota Act Made national origin the basis
for admission into the United
States
1942 Bracero Agreement Allowed Mexican nationals to
migrate to the United States as
temporary agricultural workers
1948 Displaced Persons Act Created a national displaced
persons policy
1962 Migration and Refugee Assis-
tance Act of 1962
Allocated funds to people
fleeing to the western
hemisphere from countries of
origin because of persecution
or fear of persecution based
on race, religion, or political
opinion
1965 Immigration and Nationality Act
of 1965
Eliminated the national origin
system and replaced it with
an emphasis on family-based
immigration
1980 Refugee Act of 1980 Established a new system to
process and admit refugees
fleeing from overseas and those
seeking asylum in the United
States or at US borders
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The Intersection of Racism, Immigration, and Child Health 67
Chapter 10
Immigration and Nationality Act of 1965, which abolished quotas based on national
origin. Simultaneously, immigration enforcement by immigration officials has evolved
to prioritize detention and deportation. Since the 1990s, expanded militarization at the
border, expedited deportations, and residential and work site raids have increased the
criminalization of immigrants, particularly those who are undocumented.14,15 Federal
287(g) programs, in 24 states as of January 2023, extend the reach of Immigration and
Table 10–1 (continued)
Year Act Description
1996 Personal Responsibility and
Work Opportunity Reconcilia-
tion Act of 1996
Excluded many immigrants
from participation in public
programs
2012 Deferred Action for Childhood
Arrivals
Deferred action policy that
shields some undocumented
immigrants who came to the
United States as children from
deportation and provides them
with work authorization
2017 Muslim ban A presidential executive order
banning travel from 7 predom-
inantly Muslim countries (Iran,
Iraq, Libya, Somalia, Sudan, Syr-
ia, and Yemen) and suspending
Syrian refugee resettlement
2018 Zero-tolerance/family
separation policy
Criminally prosecuted all
migrants entering the United
States without authorization,
leading to the separation of
children from their families
2019 Public charge rule change Broadened the existing
definition of a public charge to
include people who have used
anti-poverty programs such as
Medicaid, the Supplemental
Nutrition Assistance Program,
and public housing. This new
rule was reversed in 2021.
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Customs Enforcement by allowing local and state authorities to act as immigration
enforcement agents who can detain undocumented immigrants.
Across federal, state, and local jurisdictions, disproportionate policing of Black people
results in larger numbers of Black immigrants being detained and deported. Between
2003 and 2015, Black immigrants made up 5.4% of the overall undocumented population
in the United States but represented 10.6% of all immigrants in removal proceedings.
In 2015, Black immigrants made up 7.2% of all immigrants without citizenship yet made
up 20.3% of immigrants in deportation proceedings.16 There is no evidence that Black
immigrants commit crimes at greater rates than other immigrants; these disparities
indicate systemic anti-Blackness within the immigration legal system. This bias was dis-
played in September 2021 as US border agents forcibly removed Haitian migrants at the
US-Mexico border, sometimes yielding whiplike cords.17 Additional immigrant groups
that are adversely affected by racial profiling and enforcement include Latin American,
South Asian, Middle Eastern, and Muslim communities, an effect further deepening
inequities between immigrants of color and white immigrants, and, more broadly, white
Americans.8,18
Immigration Policy and Child Health Inequities
Immigrant disparities in child health outcomes illustrate the adverse legacy of ongo-
ing policy inequities. Children in immigrant families are more likely to be uninsured,
including 10% of citizen children with a noncitizen parent, 17% of lawfully present
immigrant children (including refugees), and 28% of undocumented children (includ-
ing unaccompanied immigrant children), than the 4% of citizen children with citizen
parents.19 This inequity leaves children who may experience greater medical and mental
health needs without consistent access to care.20 Additionally, children in immigrant
families experience disparate poverty rates compared with children in nonimmigrant
families (20.9% vs 9.9%).20 However, they benefit less or are excluded from critical
anti-poverty programs, including the Earned Income Tax Credit program, the Child
Tax Credit program, and the Supplemental Nutrition Assistance Program.2 Finally,
increased immigration enforcement has been linked to adverse child health outcomes.
For instance, the 2017 Muslim ban was associated with preterm births among women
from banned countries21 and immigration raids have been associated with increased
rates of low birth weights among Hispanic women.22
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The Intersection of Racism, Immigration, and Child Health 69
Chapter 10
The Role of Data in Dismantling Immigration-Related
Racism
Through research, public health, and quality improvement, pediatric health profes-
sionals can collect disaggregated data that better reflect risk profiles. This data can
elucidate, for instance, how the health of individuals born outside the United States and
emigrating from different regions or Indigenous cultures of Latin America differs in
response to changing immigration policies, as well as how structural racism and color-
ism affect the health of immigrant Asian or Black subgroups. Widespread collection of
disaggregated data will facilitate multisite research and quality improvement that can
help overcome statistical challenges when studying disaggregated groups.23 Pediatric
health professionals can consider collecting nativity data in addition to race and eth-
nicity data to create demographic categories that capture intersecting racially minori-
tized dimensions (eg, “Hispanic Black person born outside the United States”). Other
frameworks for patient descriptors may also be useful. For instance, the framework
PROGRESS-Plus (Place of residence, Race/ethnicity/culture/language, Occupation,
Gender/sex, Religion, Education, Socioeconomic status, and Social capital, Plus other
personal and relational features such as sexual orientation, disability, age, immigration
status, and educational attainment) offers a more comprehensive approach.24
To fully understand the intersection of racism, immigration, and child health, it is
essential to examine how data on race, ethnicity, and language preference has been
collected, given well-documented inaccuracies, particularly within electronic health
records.24 Equally important is using data to document structural racism and xeno-
phobia. For example, indices that score states’ structural xenophobia1 or data sets that
analyze immigrant sanctuary policies25 are examples of tools to go beyond the examina-
tion of race, ethnicity, and nativity on an individual level to the examination of societal
structures instead.
Summary
The complex and racist history of US immigration policy and enforcement threatens
the health and well-being of children in immigrant families. Through clinical, edu-
cational, research, and advocacy strategies, pediatric health professionals can help
advance health equity for all children in immigrant families.
Recommendations
Patient- and Family-Directed
 Use trained interpreters in all encounters for families who prefer languages other
than English.
 Screen for social determinants of health, including immigration-related issues.
 Provide trauma-informed care that acknowledges immigration-related trauma.
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 Address the unique health needs of unaccompanied immigrant children who have
been reunited with sponsors in communities.
 Consider language access when making referrals, including the process by which
patients schedule appointments.
 Engage in ongoing personal education to deliver care that embodies cultural humility
and safety.
Clinical Practice/Organizations/Systems
 Systematically train all team members to effectively engage with interpreters and con-
firm bilingual and multilingual staff’s fluency through formalized language testing.
 Create inclusive health care environments that explicitly welcome immigrants, such
as welcoming signage (eg, “All are welcome”) in languages that represent patient
populations.
 Educate and prepare staff about immigrants’ rights concerning immigration
enforcement.
 Query accuracy of race, ethnicity, and language data collection within electronic
health records.
 Collect disaggregated data, informed by frameworks such as PROGRESS-Plus, that
better identify characteristics driving health inequities.26
 Support cross-sectoral collaborations with sociologists, political scientists, and
demographic researchers to better measure the effect of structural racism and xeno-
phobia on immigrant health.
 Develop medicolegal partnerships in the clinical space or as external referrals to
connect families with a path to stable legal status.
 Create paid family advisory boards that include families with preferences for lan-
guages other than English.
Public Health Policy and Community Advocacy
 Engage with professional organizations with advocacy agendas to enhance collective
impact.
 Contribute to state-based efforts to expand insurance coverage for immigrant
children.
 Participate in local, state, and national coalitions to protect immigrant families’ civil
rights.
 Authentically engage with local neighborhoods by participating in or creating
community-based events sponsored by your institution.
 Work with and amplify the work of local community-based immigrant advocacy
groups.
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The Intersection of Racism, Immigration, and Child Health 71
Chapter 10
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