Immigration Policy is Health Policy
This is part of our special feature, Public Health in Europe.
As rates of immigration have risen in recent years, so have questions and concerns about the health needs and care delivery challenges for newly arrived populations. Do immigrants have unique health profiles or risks? Do migrants face barriers accessing care that might otherwise be available to them? Will a population influx, particularly when arrivals may be vulnerable to unique risk factors, strain existing health care systems?
The answers to these questions may not just involve changes to health policy, or come from research on health and medicine. They also require attention to immigration policies and the broader social conditions that shape the context of reception—or the social, political, and economic environment into which individuals and groups migrate. A growing body of scholarship suggests that immigration policy decisions—whether it’s restrictive barriers to entry, deportation enforcement, or broader support for incorporation—can have effects on the population health of both immigrant and non-immigrant populations. Immigration policy, in other words, is also health policy.
Population health scholars have long known that many of the factors that shape patterns of health and illness lie outside of medical care delivery. Theory and research on health and health inequalities have moved progressively “upstream” to examine the social conditions that influence risk factors and exposures more proximate to illness and mortality. Researchers, policy makers, and providers increasingly target social determinants that are known to have persistent effects on health across national contexts, including income, education, housing conditions, and a range of related measures of economic and living conditions. These upstream factors are also important for immigrant populations.
However, there are also some potential social causes of illness that are unique to immigrant populations and their descendants. For instance, the employment, housing, or mobility prospects of immigrants may be determined by destination-country characteristics, such as patterns of residential segregation, acts of discrimination and social exclusion, or legal barriers to resources and services for non-citizens. Some of the social experiences that go along with the migration process—from the arduous initial movement to coping with nativist backlash—are also unique sources of stress that can have deleterious effects on health and wellbeing.
Ultimately, the context of reception for different groups across different destination contexts is formed in part through immigration policy—both individual policy decisions and enduring patterns of institutional approaches to immigration. Cross-national research has become invaluable for empirically and theoretically understanding the similarities and differences driving patterns of population health inequalities (Beckfield, Olafsdottir, and Bakhtiari 2013). It has helped researchers uncover both a universal association between socioeconomic status and health—including in countries with universal and effective health care systems—as well as substantial variation in the magnitude of the association across countries. Mapping such variability in health inequalities moves theoretical focus even further upstream to macro-level political, social, and economic conditions that distribute risk and resources across countries. Although health scholars have made progress in examining the health effects of political institutions such as the welfare state, research into the links between immigration policy configurations and health is still in its early stages.
Immigrant Health Across Contexts
Growing evidence in this burgeoning area of study suggests restrictive approaches to immigration and immigrant incorporation are broadly associated with worse health for immigrant populations. Much of this evidence comes from comparisons across Europe that rely on varying methods of classifying immigration policy contexts. For instance, immigrants in European countries classified as “exclusionist” tend to fare worse, in terms of self-rated health, than immigrants in countries with “assimilationist” or “multi-cultural” approaches (Malmusi 2015). Similar associations between restrictive or exclusionary immigration policy and poor health have been found in exploratory studies of mortality differences (Ikram et al. 2015), as well as birth outcomes, such as low birth weight and preterm birth (Villalonga-Olives, Kawachi, and von Steinbüchel 2016).
This influence of exclusionary or restrictive immigration policy is not just seen in immigrant population health, but also in the patterns of relative health inequalities between minority immigrant populations and the non-immigrant majority. Moreover, it is valuable to distinguish between immigration policy—concerned with controlling the flows of movement into a country—and other policies that focus on the incorporation of immigrants once they arrive. Aligning with other findings, there is mounting evidence that institutionalized efforts to facilitate incorporation can be beneficial to the health of immigrants. European countries that adopt policies to protect immigrant groups from discrimination—measured using the Migrant Integration Policy Index (MIPEX) assessment of immigration policy components—tend to have lower relative health inequalities than countries with fewer protections (Bakhtiari, Olafsdottir, and Beckfield 2018). This pattern extends across both self-rated health and activity limitations, and it includes both first-generation and second-generation immigrant populations.
The ultimate consequences of immigrant incorporation approaches are often not limited to the foreign-born population, but extend to the broader communities of second-generation immigrants, as well as non-immigrant members of co-ethnic minority populations. Immigration policy—in both its intent and consequences—is not just about immigrants or immigration. Often, political rhetoric and policy changes serve to reinforce what sociologists call symbolic boundaries that differentiate between groups of “us” and “them” in a given social context. In the United States, for instance, discourse about undocumented immigration often instigates a broader process of boundary drawing that marginalizes Mexican and other Hispanic populations. In Europe and other destination contexts, similarly, discourse about immigration is difficult to disentangle from a broader set of symbolic boundaries drawn along lines of religion, as recent arrivals have come from Muslim-majority countries of the Middle East.
Because of such complex social dynamics and population characteristics, understanding the determinants of immigrant health is increasingly important to broader scholarship and interventions focused on population health disparities in general. Research on racial or ethnic disparities is at times disconnected from research on immigrant health. However, understanding either in an increasingly mobile world requires integrating the two lines of inquiry.
Challenges and Unanswered Questions
There is still much we don’t know about the unique factors that distribute risk for immigrant groups, in part due to some unique empirical and theoretical challenges. From a population health perspective, developing a clear empirical understanding of immigrant health profiles, and how they compare to non-immigrants in a context, is not straightforward. Some studies have found immigrants to be healthier than average, some have found them to be less healthy, and the pattern of course varies across context and immigrant group. In a field that frequently relies on comparisons of definable populations or categories, the dynamics of the immigration process make between-group analysis challenging. The predicted state of an immigrant’s health may depend on when, how, and why he or she migrated.
There are some consistent findings. A wide range of research from a variety of countries and contexts confirms that new immigrants tend to be relatively healthy when compared to their non-immigrant counterparts, particularly considering their often-disadvantaged socioeconomic profiles and other risk factors. There are a few straightforward reasons for this. Moving across large distances can be arduous and tends to happen more often among individuals who are healthier, younger, and with perhaps greater resources relative to the general population or those who don’t migrate. For these and other reasons, scholars often expect new arrivals to be relatively healthy. But this initial “health advantage” often fades within a few years or by the second generation.
This dynamic—relatively healthy new migrants whose health profiles change with duration of residence—makes population health research complicated. It is possible to simultaneously have an immigrant population that appears relatively healthy on average but also experiences elevated risks that may be detrimental to health over time or for non-immigrant members of similar ethnic or racial groups. It is difficult to operationalize immigration status in a simple or straightforward way because risks and outcomes change throughout the migration and settlement process. In many ways, the interesting focal point is the post-migration trajectory—what happens to migrant health after migration and how that varies across groups and contexts.
This dynamic also complicates the study of the health effects of immigration policy. Restrictive immigration policy can theoretically work in two directions. For new immigrants, policies that create additional barriers to entry may exacerbate selection mechanisms in a way that leads to a healthier population of new immigrants. Historically, explicit exclusion on the basis of health has played a major role in shaping immigration dynamics. Medical inspections were routine for immigrants entering the United States through the famous Ellis Island port of entry in the nineteenth century, as was denial of entry on the basis of illness. Although health inspections still factor into many countries’ entry policies today, health selection doesn’t have to operate through direct medical examination. Any policy that alters the criteria for immigration also tips the scale in how the demographics of the immigrant population differ from both the sending-country and arrival-country populations.
But cross-national analysis of policy and population health is tricky because the same policy configuration that selectively favors healthy immigrants can have subsequent detrimental consequences for migrants who do make it across borders. Consider examples from the United States, where a militarized immigration policy and state-level variation in documentation requirements have created unique natural experiments for measuring the consequences of immigration enforcement. In the months after a large federal raid on undocumented migrants in Postville, Iowa, increased rates of low birth weight births were observed not just for foreign-born Latina migrants who were among the primary targets of the raid, but also for US-born Latina mothers who were part of the broader community in the area (Novak, Geronimus, and Martinez-Cardoso 2017). The immigration process on its own can be a stressful undertaking, and evidence suggests a restrictive approach to immigration can exacerbate that stress, and not just for the foreign-born.
There are also data limitations to answering questions about some of the complex population dynamics that result from immigration, particularly across contexts. Many of the best sources of data for studying health and mortality, such as national vital statistics records, either don’t collect key information on immigration status or are too incompatible to harmonize across national contexts. Understandably, many countries in Europe balk at the collection of racial or ethnic identifiers. But the dearth of data on key demographic variables prevents comparison of the health profiles of minority and immigrant populations across countries. In the absence of comparable health and mortality records, researchers have relied on cross-national surveys, such as the European Social Survey. Although these are often limited to self-reported assessments of health, they have opened the window for cross-national comparisons of immigrant and minority health.
There are also migration complexities to consider. Immigrant health scholarship tends to be segmented by type of migration. The “healthy migrant” model works best when examining voluntary labor migration, in which decisions and opportunities for movement play a role in health selection. Much of the migration into Europe in recent years has been involuntary movement, as populations displaced by conflict and turmoil have sought refuge en masse. Not only are the selection mechanisms different under such circumstances, but displaced populations also experience unique stressors and risks that can take a toll on the body and manifest in both short-term and long-term health problems. Scholarship on the topic of immigrant health is challenging due to differing health concerns and experiences between documented and undocumented migrants and between different ethnic groups or countries of origin.
As rates of immigration have increased and shifted in form, many governments in Europe—at both the national and local level—have debated and enacted policies intended to either restrict the entry of new immigrants or govern the integration practices of migrants already there. This response has not been uniform, and in many cases either reinforces or reverses existing approaches to immigration. Some countries tend to restrict new immigration, whereas others are more open. Some have explicit protections for migrants and minorities, and resources for facilitating incorporation, while others do not. The consequences of such policy decisions not only affect the rates of entry and exit, but also the lives and life chances of migrants once they arrive. Analyzing how and why is complicated, but it’s also important for advancing our understanding of immigration, inequality, and the broader social and political determinants of health and illness.
Elyas Bakhtiari is an Assistant Professor in the Department of Sociology at the College of William and Mary. His research examines cross-national and historical variation in patterns of racial and ethnic health disparities.
Bakhtiari, Elyas, Sigrun Olafsdottir, and Jason Beckfield. 2018. “Institutions, Incorporation, and Inequality: The Case of Minority Health Inequalities in Europe.” Journal of Health and Social Behavior 59 (2): 248–67. https://doi.org/10.1177/0022146518759069.
Beckfield, Jason, Sigrun Olafsdottir, and Elyas Bakhtiari. 2013. “Health Inequalities in Global Context.” American Behavioral Scientist 57 (8): 1014–39. https://doi.org/10.1177/0002764213487343.
Ikram, Umar Z., Davide Malmusi, Knud Juel, Grégoire Rey, and Anton E. Kunst. 2015. “Association between Integration Policies and Immigrants’ Mortality: An Explorative Study across Three European Countries.” PLoS ONE 10 (6): e0129916. https://doi.org/10.1371/journal.pone.0129916.
Malmusi, Davide. 2015. “Immigrants’ Health and Health Inequality by Type of Integration Policies in European Countries.” The European Journal of Public Health 25 (2): 293–99. https://doi.org/10.1093/eurpub/cku156.
Novak, Nicole L., Arline T. Geronimus, and Aresha M. Martinez-Cardoso. 2017. “Change in Birth Outcomes among Infants Born to Latina Mothers after a Major Immigration Raid.” International Journal of Epidemiology 46 (3): 839–49. https://doi.org/10.1093/ije/dyw346.
Villalonga-Olives, E., I. Kawachi, and N. von Steinbüchel. 2016. “Pregnancy and Birth Outcomes Among Immigrant Women in the US and Europe: A Systematic Review.” Journal of Immigrant and Minority Health, August. https://doi.org/10.1007/s10903-016-0483-2.
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Published on June 11, 2019.