Guiding Principles for Writing About Immigrants and Immigrant Health

There is increasing awareness about the power of language to frame our thinking. In clinical medicine, this has been most evident by the transition to and adoption of person-first language that advocates for people to be placed before their illnesses e.g., “patient with diabetes” rather than “diabetic” patient. Studies have shown that negative language in health records can undermine the physician-patient relationship and compromise care by perpetuating stigma and communicating discriminatory beliefs between clinicians [1,2]. Some of these changes have even been bolstered by policy changes, such as Rosa’s Law passed in 2020 that removed the terms “mental retardation” and “mentally retarded” from all federal documents and inserted “having intellectual disabilities” in their place.

This shift in language use can similarly be found in the health equity literature. Most recently, the American Medical Association and the Association of American Medical Colleges released a report titled “Advanced Health Equity: A Guide to Language, Narratives, and Concepts” reviewing some of harmful language commonly used and offering equity-centered alternatives [3]. We offer this perspective article in the same spirit, with the intention to help clinicians and researchers identify harmful phrasing and frames in their own work relating to immigrant health and provide alternatives that move us toward equity for all.

We organize these recommendations within two broad categories, one focused on terminology and the second focused on changing frames around immigration discourse, although there can be overlapping principles and these categories are not mutually exclusive. Frames communicate information in a way that promote a particular understanding, presenting a certain view of a story in much the same way a picture or window frame limit what a view sees. For example, a cost-benefit frame of immigration may underline the economic contributions of immigrants to a new country but becomes mired in advancing a problematic view of immigrants’ productivity as integral to their worth or humanity.

Shifting Immigrant Terminology Toward More Humanizing Language

1. Terms like “illegal alien” are not neutral - and they conflate immigrants with criminality in a way that is highly stigmatizing. The presumption of criminality is both inaccurate (as immigration offenses are civil, not criminal) and dehumanizing, which risks bolstering arguments that immigrants are less deserving of legal protection. Alternatives that are person-first are preferable, such as “people with undocumented status,” “person applying for asylum” or “detained person”. In the U.S., we have seen a step forward with the Biden administration removing “illegal alien” from immigration-related documents.

Similarly, there is considerable debate among individuals resettled as refugees about when they no longer are considered a “resettled refugee.” As an example, a person who came to the US as a child and has citizenship may or may not identify strongly as a refugee, and research that focuses solely on their refugee-related identity can be overly simplistic. Ultimately, people are neither defined by, nor should be reduced to, their immigration status or associated traumas.

2. Much of the immigrant health literature focuses on comparisons to non-immigrant people. When scholars refer to the comparison group as “native,” when they actually mean local or non-foreign-born populations, their language use inadvertently contributes to the erasure of Native Americans and indigenous people worldwide. More colloquially in the US context, “America is a nation of immigrants” is a similarly ubiquitous statement that also prompts a problematic erasure of the full story of America, which should acknowledge indigenous peoples as the first true Americans [4]. The discussion and inclusion of immigrants should not occur at the expense of excluding Indigenous peoples.

3. We should avoid describing immigrants or forcibly displaced people as a “crisis” or problem of increasing numbers. This hyperbolic language not only stigmatizes immigrants but distracts from the reality that the crisis is in policies and the dehumanization of migrants; the crisis is never people seeking safety or fighting for survival. Similarly, we should avoid terminology like “flood of migrants,” which is hyperbolic, dehumanizing, and inherently buys into models that presume scarcity. Some scholars and advocates argue that high income countries like the U.S. have a responsibility to accept as many immigrants as possible given that the U.S. has directly and indirectly contributed to global conflicts, sociopolitical instability, and poverty that have triggered migration to the US and elsewhere, and necessitated people to flee their home countries.

4. Terms like “refugee” “asylum seeker” “undocumented” are legal, not clinical terms. While individuals with these statuses have different barriers to healthcare, clinicians run the risk of inaccuracy when they assume they understand the complexities of immigration status based on a legal determination. People can have similar experiences but different labels, and traumatic experiences are not exclusive to one group. Immigration statuses (and related precarity) impact health differently but not inherent to any label.

Challenging Dominant Frames in Immigration Discourse

5. Different countries have dramatically different migration situations because of the borders they share. Often, one border can be more contentious than another due to factors like racism that fuel media portrayals or political discourse that vilify certain groups of immigrants and not others (i.e., differences in media portrayal of white Ukrainian immigrants versus Haitian immigrants). In the U.S., “the border” is often used to imply the US-Mexico border albeit the U.S. also sharing a border with Canada. In this context, the problematization of the U.S. Mexico border, compared to the border with Canada, reinforces an implicit narrative that can be harmful to the people at the U.S. Mexico border, subjecting them to heightened surveillance. Further, migrants enter the country in many ways. In the U.S., more undocumented immigrants enter the country with valid visas (that thereafter expire) rather than by U.S.-Mexico border crossings, but the latter is uniquely subject to scrutiny [5]. Immigration trajectories should not be narrowed to border experiences.

6. Not all immigrants are refugees or forcibly displaced. Less than 15% of international migrants are refugees (and less so in high income countries). Research that looks at immigrants broadly can’t be said to generalize to forcibly displaced groups, and vice versa. Immigrants, including refugees and people who are forcibly displaced, migrate for reasons along a continuum of agency ranging from completely voluntary and completely involuntary (forced) factors. Based on their level of agency, immigrants face diverse sets of challenges and/or could have comparative privilege. Lumping all immigrants as one group can make it easy to miss disparities that affect groups of immigrants who had the least agency when migrating. For example, people with full voluntary agency in immigrating may have access to more wealth, education, and/or resources that make a new country more welcoming towards them. How welcoming a new country is can also impact how well immigrants can integrate into society and access resources. Forcibly displaced groups may also have unique mental health needs that may not affect immigrants at large [6].

At the same time, this recognition of disparate immigration statuses linked to disparate health outcomes, must be coupled with an understanding of differences among immigrant groups that existing catch-all racial or ethnic categories like “Asian”, or “Latino” obscure. These racial or ethnic groups are not composed of monolithic, homogenous groups and experience health disparities differently, from COVID-19 related deaths to police violence[7,8]. Lack of specificity can limit knowledge and hide disparities, thereby also limiting efforts to address them.

7. Clinicians and researchers should avoid setting up a refugee vs migrant dichotomy, such that only the latter is worthy of sympathy [9]. All refugees are migrants. Who is granted refugee status can be very subjective, involving factors such as race, nationality, language. For example, in the U.S., people seeking asylum from Nepal, Ethiopia, and China are over 4 times more likely to be approved than people seeking asylum from Haiti, Honduras, and Mexico [10]. Another determining factor for whether someone is approved for asylum is actually which judge is assigned to their case; some judges deny as high as 99% of asylum cases that are assigned to them, while some only reject around 10% of cases [10]. This discrepancy further shows the lack of objectivity inherent in the legal process and why we should not allow legal determinations to drive the treatment and support that people receive.

8. Mistrust of healthcare systems has been implicated as a critical contributor to health disparities, with particular attention paid to Black Americans who have been subject to historical and current violations by the medical field. However, many scholars have argued that the term mistrust is victim-blaming, when lack of trust toward healthcare providers and organizations who continue to discriminate is fully justified [11]. This applies to immigrants as well. Mistrust serves a purpose–to protect individuals who have been repeatedly let down by an establishment; therefore, we must reframe our discussions to be less about the individuals who must learn to trust and more about clinicians or healthcare systems who must build or rebuild trustworthiness. Some healthcare facilities have begun to adopt policies and actions to welcome immigrants, but there is a need for continued shifting of focus on the locus of responsibility from the individual to the provider or organization [12].

Whether we fulfil clinical, research or hybrid clinical-researcher roles, we must lead the way on modeling non-stigmatizing and accurate language in our work, particularly when it is being done by individuals from outside of the communities being studied. The movement towards Community-Engaged Research and power-sharing with communities being studied is a critical movement towards unpacking the ways in which the immigrant health practice and research can inadvertently perpetuate the very structures of power that many of us seek to dismantle in the name of equity. We also recognize that this is not a comprehensive list of potential pitfalls and awareness of equitable language practice should continue to develop. Ultimately, as clinicians and researchers committed to equity and well-being for immigrants, we have the opportunity to ensure that our research questions, language and structures mirror these important principles.