Ten years ago, a New York Times article entitled “The Health Toll of Immigration,” summarized a key finding from decades of research on immigrants’ health in its opening line: “Becoming an American can be bad for your health.” The article highlighted the well-documented pattern that shows that the relatively good health of immigrants erodes with time in the United States and across generations. Discussing potential explanations for this pattern of declining health, the article pointed first to studies that suggested immigrants adopt unhealthy behaviors characteristic of the default American lifestyle—such as eating fast food—and abandon healthier behaviors of their countries of origin, such as consumption of “traditional” foods.
This explanation, common in the media and research literature alike, is convenient and simplistic—not to mention rooted in stereotypical notions of the United States and its food and health environments as “modern” and those of immigrant-sending countries, primarily from the Global South, as “traditional.” In focusing on individual health behaviors, this explanation places the burden of blame for declining health on immigrants themselves, ignoring—and thereby absolving of blame—the complex matrix of structural forces that harm immigrants’ health.
This explanation is also incomplete because health behaviors are not the sole factors that shape health. But even with the recognition that health behaviors represent one of many determinants of health, the explanation is still incomplete without examination of a crucial follow-up question: Why might immigrants adopt less healthy behaviors over time in the United States?
Addressing this question helps us to begin to make sense of the persistent finding that immigrants’ health declines over time and across generations in the United States so that we can get at the deeper question at hand: What is it about the United States that is harmful to immigrants’ health?
The short answer: it’s not the French fries. The long answer requires consideration of how U.S. population health is highly stratified by social factors such as race and socioeconomic status, with the most privileged groups enjoying the most favorable health outcomes. As immigrants become incorporated into the U.S. racial and social order, their health profiles, including their health behaviors, increasingly reflect, or result from, their social position in the United States—a position that is largely one of disadvantage due to a pervasive climate of exclusion toward immigrants.
Climates of Exclusion
Climates of exclusion are fueled by a dense web of federal, state, and local laws; discrimination; and anti-immigrant sentiment. Rooted in a legacy of institutionalized racism and exclusion that began with the country’s first citizenship law in 1790, which was designed to keep the nation white by extending formal citizenship through naturalization to whites only, today’s climate of exclusion is nothing new. Although the intensity of exclusion ebbs and flows, flaring up more strongly in times of economic or political crises, it is always there. Even policies intended to be more inclusive have often had unintended consequences of exclusion. For example, the Immigration and Nationality Act of 1965, which was intended to eliminate racism in immigration laws, had the unintended consequence of triggering sharp increases in undocumented migration by instituting caps on legal migration. As immigration journalist Caitlin Dickerson wrote (login required), “It’s [U.S. immigration policy] always been about exclusion.”
Like many exclusionary practices in the United States, the exclusion of immigrants shifts form over time, but the purpose of maintaining power and privilege remains the same. Although U.S. naturalization laws no longer explicitly deny citizenship to anyone who is not considered white, there are new manifestations of exclusion. Contemporary exclusionary practices toward immigrants take various forms—overt and subtle; formal and informal; and at the micro-, meso-, and macro-levels—that restrict legal and symbolic belonging for immigrants, their children, and in certain instances, U.S.-born coethnics who are often racialized as immigrants.
Exclusion is most pronounced for the country’s 11 million undocumented immigrants, many of whom migrated to the United States as young children and feel culturally and socially American or whom have lived more than a decade in the United States have U.S.-born children, and are members of their local communities. Because of their time in and roots in the United States, the majority of the undocumented population can make claims to belonging in the United States, but they lack formal citizenship or any pathway to it; live under constant threat of deportation and detention in centers with inhumane conditions; were excluded from federal Covid-19 relief despite providing essential labor through the pandemic; work, even as minors, in low wage and risky jobs; and navigate their lives in a state of limbo.
The exclusion of undocumented immigrants is maintained through Congress’s decades-long inaction on federal immigration reform and through increasingly punitive immigration enforcement policies. But exclusion starts before migrants set foot in the country, with the United States signaling its stance on the admission of immigrants, asylum seekers, and refugees through, for example, recent proposals to severely limit asylum, or through Vice President Kamala Harris’s blunt statement to Guatemalan migrants: “Do not come.”
Exclusion continues when immigrants first arrive in the United States., with thousands enduring the trauma of one of the most egregious human rights violations in recent U.S. immigration policy history—the family separation policy—and others getting involuntarily bussed or flown across the country from Texas and Arizona for political show.
And exclusion endures over immigrants’ time in the United States and extends beyond undocumented immigrants, often spilling over to U.S.-born children of immigrants, legal permanent residents, naturalized citizens, and coethnics, and across the socioeconomic spectrum through anti-immigrant sentiment that ranges from microaggressions and bullying to racist rhetoric and hate crimes.
The Toll of Exclusion on Immigrants’ Health throughout the Life Course
The cumulative impact of exclusion on the body is real. Although today’s climate of exclusion is not a new phenomenon, what differs today from the past is that we now have mounting evidence—from researchers in sociology, demography, anthropology, psychology, education, public health, and medicine—that this systemic exclusion carries significant short- and long-term costs to physical and mental health for immigrants, their children, and even U.S.-born coethnics. Climates of exclusion work insidiously through direct and indirect pathways to impact health throughout the life course. I highlight a few examples of that evidence here.
Infancy and childhood. The health consequences of exclusion start in utero, with babies born to immigrant mothers experiencing worse birth outcomes following immigration enforcement raids and the passage of restrictive immigration laws, as well as during the Trump era. The consequences persist into early and middle childhood, with adverse, and in some cases severe, effects on child development, mental health, and health-care access. For example, I have found through my own work that immigrant children in states with restrictive immigrant policies are less likely to have health insurance or an annual doctor’s visit. Moreover, exclusion at this critical developmental life course stage leaves a lasting imprint that endures into adulthood. A recent study showed that adults who experienced the trauma of chronic exposure to immigration enforcement episodes in childhood experienced long-term negative socioemotional effects into adulthood.
Adolescence and early adulthood. In adolescence and early adulthood, exclusion becomes internalized and manifests primarily, though not solely, through adverse mental health outcomes. For example, undocumented Mexican young adults and Mexican American young adults who were racialized as undocumented immigrants report suffering psychological stress from discrimination related to the stigma of their perceived illegality. The undocumented 1.5 generation—those who arrived in the United States as children without legal immigration status and have grown up in the United States—confront unique mental health challenges as they transition from social inclusion as children in the U.S. K‒12 system to legal exclusion as adolescents and young adults. For one of the most vulnerable immigrant populations—unaccompanied, undocumented Latin American minors—the impacts of exclusion are particularly deleterious. They face unsafe and exploitative work conditions and family disruptions that impose physical and mental health stressors.
Middle and older age. The physical embodiment of exclusion emerges most acutely in middle and older age. We see this among older Latin American immigrants, who have longer life expectancies than U.S.-born whites—the most health advantaged group—but shorter healthy life expectancies; that is, they live longer but in worse health. This pattern may be evidence of weathering, or a rapid decline in aging brought on by the cumulative toll of structural discrimination over one’s lifetime. The issue of aging while undocumented also presents serious health concerns. In this life course stage of increased health needs, older undocumented immigrants, who comprise at least 12 percent of the undocumented population, confront major challenges to health-care access throughout old age and end-stage illness, as they are locked out of Medicaid, Medicare, and other social safety net programs
Looking Forward
With immigrants comprising 13.6 percent (or 45.3 million) of the U.S. population and their children comprising 26 percent (or 18 million) of the U.S. youth population, it would be easy to use these large numbers to make a case for why investing in the health of immigrants and their children matters for U.S. population health and for the economy: Who will provide essential (and cheap!) labor if immigrants are sick? Sicker immigrants will strain the already overburdened U.S. health-care and public benefits systems! But such arguments are counterproductive because they reinforce an exclusionist framework. Too often, public support for immigrants is linked to discourses of (un)deservingness that condition benefits or services for immigrants on their economic productivity. Such reasoning reifies stereotypes of “good” and “bad” immigrants based on their economic contributions, reducing their humanity to the value of their labor. Immigrants’ “deservingness” of health, well-being, and health care should not be contingent on their economic contributions. The health of immigrants matters because health is a human right.
The health toll of exclusion on immigrants over the life course provides yet another example of how, in the United States, pernicious structural inequalities “get under the skin” to create, reproduce, and maintain inequities in health, which in turn reinforce inequities in other dimensions such as education and income. Thus, maintaining systems of exclusion that systematically harm health is both inefficient for society and immoral. Although dismantling such systems seems an overwhelming task, growing evidence shows that progress is possible. Inclusive immigrant policies are associated with improved outcomes for immigrants, such lower levels of poverty, higher rates of health insurance, and better mental health. The takeaway from these studies is that such policies represent a modifiable determinant of health that can be used to reduce health inequities.
To close, I return to the line from the New York Times article that suggests that becoming an American can be bad for immigrants’ health. In the decade since the article was published, the scientific literature on immigrant health has continued to shift away from individualistic behavioral explanations of immigrants’ health toward structural explanations that emphasize the social determinants of health such as the systemic climate of exclusion toward immigrants. This shift in our understanding of immigrants’ health necessitates a revision of the idea that “becoming an American is bad for your health.” A more accurate assessment based on current research in this era of exclusion would be that, for immigrants, not becoming American is bad for one’s health—or more aptly said, being denied the opportunity to become fully American is bad for one’s health.
Any opinions expressed in the articles in this publication are those of the author and not the American Sociological Association.
