People are on the move — that’s according to the nonpartisan Migration Policy Institute, a Washington, D.C.-based nonprofit that tracks immigration patterns and seeks to improve immigration and integration policies in the United States and abroad.
Their March 2023 statistics show that nearly 45.3 million immigrants lived in the United States in 2021, comprising 13.6% of the total U.S. population. Between 2019 and 2021, 337,000 foreign-born individuals moved to the United States. In 2022, the institute found, legal permanent and temporary immigration resumed its climb after a decline amid the COVID-19 public health crisis and the previous administration’s restrictive policies.
They have come for many different reasons.
In some cases, migration has become an imperative, as climate change, civil unrest, gang violence, and many other factors converge to uproot people the world over. In large part, the displaced flock to several countries in the global north, including the United States, in search of better, safer opportunities for themselves and their children.
But such human migration can bring significant public health challenges, including disruption to basic preventive health care such as routine childhood vaccines.
Migration and human movement are two of the main causes of disease spread, says Deliana Garcia, chief program officer, International and Emerging Issues with the Migrant Clinicians Network (MCN), a nonprofit headquartered in Austin, Texas, that aims to remove barriers to health care for migrants, immigrants, asylum seekers, and other historically marginalized communities. Garcia says this is a problem the world saw up close during the COVID-19 pandemic that crossed borders and geopolitical boundaries with ease.
Several groups are aiming to address these challenges. It’s a big task taking place in several parts of the country from many different angles to cover the wide range of health services new immigrants and their families may need.
Reaching Populations in Flux
“Health care is not one-dimensional,” says Shantell Cheek, RN, MAEd, uninsured programs director and HealthAssist coordinator for Access East, a Greenville, North Carolina-based nonprofit that helps underserved and historically marginalized individuals in Eastern North Carolina navigate complex health issues and access care with the goal of improving health outcomes. The organization provides funding to cover the costs of the associated programs.
“If your housing isn’t correct, you’re not going to think about health care,” she says. “Or if you have transportation issues, you’re facing another barrier to get to an appointment.”
Outreach groups like Access East aim to address some of these social and financial factors by bringing health care to migrant farmworkers, offering transportation and providing other services to support the health care needs of this diverse population.
Such efforts often include initiatives focused on vaccinating the young children of immigrants who arrive in the United States to protect against preventable infectious diseases and so that they can enroll in school and work towards building their own brighter futures.
One such program, a mobile pediatric clinic program in Florida called SHOTZ-2-GO! offered by the University of Miami’s Pediatric Mobile Clinics group, is improving health outcomes for immigrants and their families. The UM program works to get school-aged children in vaccine compliance to enroll in local schools.
Lisa Gwynn, DO, MBA, MSPH, associate professor of clinical pediatrics and public health sciences at the University of Miami Leonard M. Miller School of Medicine, leads the program, which uses two mobile units to provide vaccines and well visits for newly arrived children.
The program is more than 30 years old, which means “the community knows about us and we get invited to a lot of health care and back-to-school events and so forth, and that’s how we’ve become so embedded in the fabric of the community,” Gwynn says.
By partnering with Miami Dade County Public Schools and the Florida Department of Health, the University of Miami Pediatric Mobile Clinic, which delivers routine health care to children, has reached thousands of children in Miami-area schools over the years. From July 2022 to June 2023 alone, the pediatric mobile clinic recorded more than 3,350 medical encounters and worked with more than 2,700 unique patients. The group administered 6,688 vaccines (not including COVID-19 or Flu) along with 468 COVID-19 vaccines and 562 flu shots.
The SHOTZ-2-GO! Team, which falls under the umbrella of the Miami Pediatric Mobile Clinic and focuses specifically on vaccinations, was also busy during that same time period administering 9,042 vaccines (not including COVID-19 or flu) and working with nearly 7,000 unique patients. It all adds up to scores of children accessing health care that they might otherwise miss out on.
While programs such as SHOTZ-2-GO! have made significant inroads, there can be myriad challenges associated with providing public health services to newly arrived immigrants.
That’s in part because they are not a monolithic group. Some newly arrived individuals have fled civil war or drug-related gang violence in their home countries. Some have migrated to the United States for economic reasons or because climate change has made the living conditions at home untenable.
Regardless, seeking a future in the United States comes with a host of challenges, among them financial, cultural, and language barriers.
In Florida, specifically, Gwynn says a major hurdle is a lack of affordable health insurance.
“There is CHIP-funded insurance, but the premiums are on the high side, especially for families that have more than one child. So oftentimes it’s unaffordable,” she says of the Children’s Health Insurance Program, which is available to lawfully present immigrants. CHIP insurance covers qualified noncitizens who meet income and residency rules. The program offers health coverage for routine, preventive childhood care such as well visits, dental care and diagnostic and emergency health care needs.
While vaccines offered to anyone under the age of 18 are free of charge thanks to the federally funded Vaccines for Children program, the providers who deliver the shots can charge a fee for the office visit, and sometimes that cost is prohibitive for families.
Fear of Authority
“There’s also a fear factor that comes into play sometimes where they don’t even want to go down that road because they may not have the appropriate documentation,” Gwynn says.
Some worry that accessing public health services at a health fair or similar event means they’ll be tracked and reported to immigration authorities and eventually deported.
To help offset this concern, some programs like Access East leverage the experiences of staff members to forge trusting connections with migrant communities.
Juan Allen, farmwork community coordinator at Access East travels to farms around eastern North Carolina where he, as a native Spanish speaker who himself emigrated from El Salvador, is able to connect with the migrant farmworkers he meets, helping to bridge that gap between fear and acceptance.
“My daily work … is going to the farms and seeing what’s going on. Talking to people, being involved and engaged with the community and the community health centers. We’re doing outreach to connect [with migrant farm workers] and try to deliver services,” he explains.
Allen says his group also works with The East Coast Migrant Head Start Project to support migrant and seasonal farmworkers and their families by providing wellness education and public health services, which includes vaccinations for kids.
Despite those grassroots efforts, fear and its repercussions can extend well beyond a simple fear of authority or deportation and run to complex trauma. Cheek notes that some people from these communities present with behavioral and mental health issues that need to be addressed. Some have sustained serious trauma in their home countries and managing the fallout from such can be daunting, especially when life can still seem so tenuous in a new country.
“I think what we’re learning now is the need for a lot more mental health first aid and behavioral health,” Cheek says. “We’ve always occupied that space just a little, but I think we need to increase efforts across the nation. That’s a gap that hasn’t been quite filled to capacity yet.”
Language and Cultural Barriers
In North Carolina, Allen and his team members leverage their deep cultural knowledge and native language skills to forge trust and disseminate knowledge to migrant families in need. But it’s not always easy, especially as migrant families are arriving from many locations around the globe, not just Spanish-speaking countries.
It can be difficult to serve such diverse communities and meet language and cultural needs. To get around these barriers, outreach groups like MCN employ a multicultural team that speaks the languages of the population they’re trying to serve. At MCN, all staffers are bilingual in English and Spanish, and several staffers speak Portuguese, French, or Swahili as well. For those who speak a language that staff members don’t know, the team uses a language translation service to connect them with an interpreter who can help bridge that gap.
The UM group also leverages its staff’s skills to communicate with newly arrived families.
For example, in South Florida, many people have arrived from Haiti and speak Haitian Creole, so “a couple of our nurses speak Creole,” Gwynn says.
Virtually everyone on staff also speaks Spanish and English, so they’re able to communicate with the majority of the immigrants that arrive in the region. They also use a translation line to set up a three-way conversation with an interpreter when another language is needed.
A lack of transportation options and parents who need to work multiple jobs that often don’t allow them time off to attend to their children’s health care needs can also present a major challenge to ensuring kids receive the health care they need.
Additionally, remaining in one location long enough to get the full schedule of vaccines or to follow up on basic wellness visits can be another challenge for some. Specifically for itinerant and migrant farm workers, chasing the harvest means these folks are frequently on the move.
“There are so many migrant [farmworkers] following the harvest. They’re coming from Florida, through Alabama and Georgia, then they go to South Carolina, North Carolina up to Pennsylvania, and they come back to pick up the harvest,” Allen explains.
While some families will start a vaccination schedule in Florida, by the time they get back, their child may be behind on the next dose.
“We try to refer these cases to send [records] to other [migrant health] centers for them to go and get all the vaccinations,” he says, referring to a network of sites along the East Coast that provide similar access to care.
Access East also holds clinics to help migrant families get their children’s paperwork in order and also provides cash to migrant families to cover the cost of doctor’s office visits that may be associated with getting vaccines.
A Lack of Knowledge That Services Are Available
A lack of awareness that services exist can also be a hurdle in some cases. Informing farmworkers and other immigrant populations about the services they provide is a big part of Access East’s work, Cheek says.
In all cases, Gwynn says, “I think it’s important for providers to understand the challenges that these families are facing and try to do their best to work within some of these challenges.”
This could mean offering evening or weekend hours when parents might be more available to bring their child in for care and participating in outreach events where many members of the community will already be in attendance.
Gwynn also notes that “getting out there where [patients and families] are is really the best way to connect them to care.”
The Drive to Survive
The more immediate crisis of just getting by can also be difficult for some.
“Survival is really the priority for a lot of these families,” Gwynn says.
Garcia agrees that preventive health care often takes a backseat to sheer survival.
“You have people who’ve been walking for thousands of miles for many days who are dehydrated, malnourished, stressed out, and traumatized,” she says. “They’ve been targeted by the cartels or the army, the coyotes, and other migrants.”
Many asylum seekers and refugees are so focused on their immediate survival that it can be challenging to get them to spend time and energy on getting vaccinated against a possible threat in the future.
While an ounce of prevention is always worth a pound of cure, in the immediacy of a crisis, it can be impossible for some to look ahead to ward off potential future problems that they think they might not live long enough to encounter.
A Willingness to Vaccinate
The good news, Gwynn says of the children and families she’s worked with in Miami, is “there’s never a hesitancy for vaccines. These families that are coming in, they want to have whatever their child needs to get them into school.”
“In general, I think that there is a true willingness among many immigrant groups to say, ‘Absolutely, if I have access to it, I’ve done it. If my kids have had access to it, they’ve been vaccinated,’” she says.
Especially for those coming from other parts of the Americas, “the vaccine rates in other countries are so superior to what they are in the U.S.,” Garcia explains.
But medical records are often a stumbling block.
There typically aren’t systems in many countries where such information is nationally recorded in a way where you can go back and retrieve those records Garcia says. In those cases, the child will need to be revaccinated in order to comply with regulations regarding school attendance.
Despite all the challenges, many migrant families and refuges do eventually find their way to a safe place and establish a home and a life here, and that’s what keeps Garcia motivated to help.
“They’re so appreciative in many cases,” she says. “They’re suspicious frequently because they’re fearful, but they’re also grateful for support.”
Offering positive outcomes to people who are just trying to make their lives better for themselves and their families is also a strong driver for Cheek and Allen.
“Seeing people get signed up for insurance and realizing that insurance is affordable and they don’t have to decide between paying the light bill and insurance, they can do both,” says Cheek, is what keeps her going in what can sometimes be a challenging role supporting historically marginalized people.
For his part, when Allen moved from El Salvador to the United States in 2004, he says he felt like he was treated like a “second-class human being.” As difficult as that was, having that experience informs his work where he endeavors to extend a more welcoming hand to others who’ve recently arrived.
“That gives me some kind of peace of mind,” he says.