During four decades of caring for the children of immigrants who live in the U.S. without legal permission, Stanford pediatrician Fernando Mendoza, MD, often had to ask the parents of his patients a painful question: "Have you talked to your kids about what happens if you get picked up by immigration enforcement?"
"That should not be a discussion a pediatrician needs to have in a routine check-up," said Mendoza. Yet, he wanted to ensure that his patients knew who would look after them if their parents were detained or deported. "It was heartbreaking, but at the same time it was necessary."
Now retired from clinical duties, Mendoza still studies how these immigrants navigate the U.S. healthcare system. His team's latest research, which appeared in July in Academic Pediatrics, focuses on health behaviors among young adults migrants who could easily have been his pediatric patients 10 or 20 years ago.
Study participants were still approaching health care in ways that reflected the lasting effects of their childhoods, the research found, despite that most were enrolled in the federal government's Deferred Action for Childhood Arrivals program, which provided temporary relief from immigration enforcement for immigrants who entered the country illegally as children or overstayed their visas.
"This paper suggests that much of what we do as adults comes from what we saw as kids when it comes to how we interact with the health care system," Mendoza said. "We have to understand that as a policy issue and as health care providers."
Habits from childhood persist
Stanford medical student Ghida El Banna and sociology graduate student Kimberly Higuera collaborated with Mendoza to analyze findings from in-depth interviews conducted with 48 immigrants living in six U.S. states without legal permission to assess their health behaviors. Higuera conducted the interviews between June 2017 and August 2018 for her dissertation research with Stanford sociologist Tomás Jiménez, PhD. Of the participants, 26 were parents (11 of whom are enrolled in DACA and 15 of whom were not eligible for DACA), and 22 were young adults enrolled in DACA who did not have children.
Participants with DACA reported that their access to health care improved when they received the program's protections and was better than that of family members who weren't in the program.
Parents in the study told investigators that they prioritized their children's health, regardless of their DACA status. For instance, parents with and without DACA were equally likely to take their children to the pediatrician regularly. The children of most study participants were born in the U.S., so they were eligible for public health insurance. Also, several participants lived in Illinois and California, where children can obtain public health insurance regardless of immigration status.
Prior research from the Stanford Immigration Policy Lab and Stanford Medicine showed that the children of DACA recipients had fewer adjustment and anxiety disorder diagnoses than kids of other immigrants who don't have legal status, likely because they were less worried that their parents might be deported.
Yet, while they made sure their children had the medical care they needed, DACA recipients didn't always seek out medical care for themselves, the new study found. Study participants felt constrained by their experiences of watching their own parents struggle to obtain health care as immigrants without legal status, they said.
Typically, participants' parents had access only to limited medical care from free clinics or emergency rooms. Some study participants had stepped into caregiving roles for their parents before they were themselves adults, such as by translating at their parents' medical appointments, or working to support their families when their parents were ill.
Generational stresses about care persist
For example, one participant's mother had been diagnosed at a young age with ovarian cancer, which caused stressful shifts in family roles. This experience continued to contribute to her own reluctance to go to the doctor, even though she now has health insurance, she said:
"I had to step up. So, at junior year, I took an under-the-table job at a casino. ... I worked graveyard shifts or swing shifts and I still went to high school," she said. "So, her being sick always made me feel like I was the mom. Then I didn't have DACA until I was 18. But if I am sick, I can handle it. ... I avoid everything to do with the doctor. I really do not take care of myself the way I should."
In general, comments from participants without DACA protections reflected that they didn't view medical care for themselves as necessary; that they often endured poor health before seeing a physician; and that the cost of medications and lack of permanent solutions to chronic conditions deterred them from seeking care.
Participants also described ongoing stress about helping family members who don't have legal status, such as their elderly parents, access medical care. Those who have family members without DACA or who aren't in the program themselves reported facing many barriers to obtaining medical care, such as difficulty traveling to free clinics, long wait times, and challenges completing medical paperwork.
Mendoza said he hopes that the findings will spur more efforts to understand how health behaviors persist across generations in at-risk groups. "It's so important to understand why people go to see a doctor. A large part of what we do in medicine is more behavioral than disease-driven," he said.
The study underscores the tolls that a piecemeal approach to providing health insurance takes on families where only some members are insured, he said.
"We should think about pathways to get insurance for all people who live and work here," he said. "It's not reasonable for people to see their family members having poor health and unable to get care in one of the wealthiest countries in the world."
The study was funded in part by Stanford's Maternal and Child Health Research Institute.
Photo by Kangwan