Is life in America hazardous to immigrants' health?

America is a nation of immigrants, drawn from all parts of the world by the promise of freedom and a good life for themselves and their children. But a substantial body of evidence suggests that for the newly arrived, life in the United States can be hazardous to their well-being. When they get here, immigrants are on average healthier than their native-born American counterparts. But the longer they stay, the worse they fare on measures such as heart disease, hypertension, diabetes and mental health.

The factors contributing to the declining health status of immigrant groups over time and through the generations are as varied and complex as the panoply of cultures that comprise our immigrant-rich country.

Part of it has to do with an unfamiliarity with U.S. society and its complicated health care system. Many immigrants lack health insurance. But Dr. Marjorie Kagawa-Singer, a professor at the Fielding School who focuses on developing standards for the delivery of care that appropriately considers patients' culture, notes that even when cost is removed as a factor, a number of barriers can prevent immigrants from accessing important health services. "If someone is new to this country, doesn't speak the language, and has to learn to navigate our system, it's like plopping us in the middle of Siberia and expecting us to figure out what we need," she says.

While levels of health literacy and adherence to traditions vary considerably, many immigrants across the educational and cultural spectrum hold beliefs about disease and how the body works that diverge from the biomedical model practiced in the United States, Kagawa-Singer adds, and many health care practitioners are uneducated on those differences. "When you have problems in both health literacy among patients and cultural competence among practitioners, you get this perfect storm of people who will not be able to utilize the health care system even when it's offered," says Kagawa-Singer, who since 2000 has headed the Los Angeles site of the Asian American Network for Cancer Awareness, Research and Training, the first federally funded cancer prevention and control research initiative focusing on Asian Americans.

In lectures and short courses on cultural competence, Kagawa-Singer advises health professionals to demonstrate their trustworthiness and compassion. "It's not the health problem you're treating, it's the person," she says. "When patients recognize you're making the effort and respecting their dignity, they're going to be much more forgiving and willing to teach and learn." The challenge, she notes, is that the U.S. health care system is designed for short encounters, despite the fact that it may take longer to get to know and understand patients from different backgrounds.

For some time, public health experts have postulated that immigrants decline in health as they assimilate and adopt the health habits of their communities – including diets high in fats and processed foods, along with reduced physical activity. To some extent that equation has changed with the globalization of the food supply, says Dr. May C. Wang, a Fielding School professor who focuses on early childhood obesity, including the impact of the social and physical environment. "It's less the case that immigrants are bringing their preference for traditional diets, because most low-income countries now have access to the processed foods we've been eating for the past few decades," Wang notes.

But even when their tastes are similar to those of non-immigrants, immigrants who arrive in the United States with minimal financial means face considerable challenges to eating well. "Education alone doesn't work in a community that doesn't have the ability to access healthy food," Wang says. "And in the very poorest communities, trying to change the environment by placing healthier foods where people live, work and go to school is challenging. It's hard to create the demand, and in many of these communities people don't have the resources to make the necessary environmental changes." The problem is compounded for immigrant groups, she explains, because they tend to have fewer social ties, are constricted by language barriers and often lack the know-how to pursue resources that could help them.

Wang works closely with the Public Health Foundation Enterprises (PHFE) WIC Program, the largest local WIC agency in the country, serving more than 300,000 families a year – the vast majority of which are non-English speaking immigrants. Although the overall childhood obesity rate has plateaued and in some cases declined in the United States in recent years, Wang notes, so many public health strategies have been implemented that it's difficult to pinpoint which have been most responsible. Moreover, the obesity rate among the mostly immigrant Latino children (the majority of the WIC population in Los Angeles) remains substantially higher than for other groups. Among the low-income, preschool-aged Latino children enrolled in L.A. County's WIC program in 2011, nearly 22 percent were obese. Utilizing the extensive PHFE WIC database, Wang and her colleagues are seeking to better understand the impact of various strategies to improve diet and reduce early childhood obesity. "The goal is to build the capacity for designing effective interventions that recognize the specific challenges faced by immigrant families," Wang explains. "We are examining the social and physical environments in which immigrants live and how these affect their ability to put into practice nutrition knowledge they acquire from participation in the WIC program."

It's been called the Latino Paradox – the observation that despite social and economic disadvantages, newly arrived Latino immigrants are by many measures healthier than other groups. But the evidence also shows that the longer these immigrants are in the United States, and through successive generations, the paradox disappears: Risks of chronic conditions such as diabetes, cancer and heart disease increase. "The suggestion is that they're adopting unhealthy American lifestyles," says Dr. Alex Ortega, a Fielding School professor whose work focuses on the physical, medical and mental health needs of Latino children and their families. Ortega is also principal investigator of the UCLA Center for Population Health and Health Disparities, a $10 million, five-year effort funded by the National Institutes of Health to study and reduce cardiovascular disease risk in East Los Angeles, in part by changing the local food environment.

Less attention has been paid to a similar phenomenon Ortega has studied. He has found that among children in Latino families, the longer they have lived in the United States and the more generations their family has been here, the higher the risk for poor mental health. Among the possible explanations: "As people immigrate and become acculturated, in some cases they lose family and social ties, and without those support systems they lack the safety net to help protect them from the effects of poor mental health," says Ortega, who notes that similar findings have been reported for other immigrant groups.

While some have suggested that public health strategies should explore ways to encourage immigrants to maintain the lifestyles of their home countries, Ortega believes that to be impractical. "You can't expect immigrants to come here and not become acculturated," he says. Rather, he argues, policies should seek to strengthen social networks and support for immigrants, as well as improving access to mental health services in low-income immigrant communities.

While assimilation may be a significant factor in the worsening health, on average, of many immigrant groups as they spend more time living in the United States, other factors are clearly at play, says Dr. Gilbert Gee, a professor at the Fielding School and member of the UCLA Kaiser Permanente Center for Health Equity. "The usual suspects – culture, genetics, socioeconomic status – are clearly important, but they don't fully explain the health disparities we see," he says.

In fact, Gee believes that some of what is attributed to assimilation when it comes to immigrant health trends may actually be the result of the way immigrants are looked upon in their new home. "The general thinking is that as immigrants become more Americanized, they change their behaviors – eating more hamburgers and exercising less," he says. "But another aspect of being here a long time is that you experience more discrimination."

In his work, Gee seeks to measure the impact of that discrimination on mental and physical health. He points out that immigrants go from feeling at home in their country of origin to being viewed as a racial minority. "People take shortcuts in the way they see you," Gee says. "Suddenly you're not Sri Lankan but simply Asian. Some immigrants, after 9/11, are perceived as potential terrorists. It can be stressful enough to come to a new society and learn a new language, but it's doubly stressful when you're also dealing with these negative stereotypes."

Research has consistently found associations between people's reports of discrimination and a variety of health problems, Gee says. In a study of Asian-American immigrants, his group found that clinical depression was more likely to be predicted by experiences of discrimination than by standard measures of acculturation.

For Gee, this underscores the notion that civil rights policies are also health policies. "When we're changing the way we define immigrants, that is likely to have a health impact," he says. Gee suggests that more recent efforts to pass English-only laws have created a hostile climate for immigrant groups, potentially to the detriment of their health.

Despite these concerns, Gee's studies have reminded him that immigrants tend to be a resilient population. "It takes a large measure of bravery to move to another country," he says. "If you think about uprooting your family and bringing young children to a new society, that's phenomenal."