Dismantling Structural Racism by Advancing Immigrant Health

In “Strategies for Naming and Addressing Structural Racism in Immigrant Mental Health,” Cerda et al. (p. S72) make a critical call to bring a structural racism framework into efforts to promote immigrants’ mental health. Mounting public health research shows that structures and systems of racism are associated with poor health, yet there have been limited applications of a structural racism framework to immigrant health research or practice.¹ As Cerda et al. highlight, structural racism can harm immigrants’ health through processes such as policies, workplace conditions, and treatment in mental health service settings. Building on the work of Cerda et al., we discuss how the US immigration system shapes and is shaped by structural racism. We offer recommendations for dismantling structural racism by going to the sources of racial power in research and practice, addressing the intersecting systems that harm health, and advancing antiracist multisectoral partnerships.

STRUCTURAL RACISM THROUGH IMMIGRATION POLICY

Although immigration policy often uses verbiage devoid of race and has been studied on a separate axis from other forms of structural racism,² US policy history reinforces that federal immigration policy and other nonfederal immigrant-related policies³ are mechanisms of structural racism. The US immigration system has been shaped by xenophobic and racist attitudes and has served as a tool of racial control.⁴ Immigration policies directly shape the racial composition of the nation and have contributed to the maintenance of a White-dominant society.⁵ In some cases, immigration policy has been an explicit manifestation of racist objectives, such as denial of entry into the United States for targeted groups. For example, the Chinese Exclusion Acts of the late-19th century and the Immigration Act of 1924 barred admission to individuals based on their race and country of origin.⁶ More recently, the series of “Muslim Ban” executive orders, beginning in 2017 and repealed in 2021, established country of origin–based exclusions rooted in Islamophobia, largely targeting Middle Eastern and African countries (bit.ly/3hxBgAu).

Racist objectives have also been less overt in the immigration system, instead manifesting through concepts of citizenship (e.g., legal and social belonging), safety and criminality, terrorism and national security, and economic contribution and group deservingness. Citizenship policies determining immigrants’ legal status produce subordinate social positions for noncitizens of color, bolster the nation’s racial hierarchy, and maintain White political and economic power.⁷ For example, the Bracero Program, which employed guest workers from Mexico to fill labor shortages, was terminated in 1964 when Mexican laborers were no longer needed and were viewed as an economic threat to a predominantly White, citizen workforce.⁵ Its ending caused cross-border workers to be categorized as “illegal,” resulting in a recategorization of Mexican guest workers as “illegal immigrants” undeserving of political or economic benefits.⁵ The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which was aimed at welfare reform, established a five-year waiting period for those who were newly arrived and were predominantly Latinx (a gender-inclusive term we use to describe the population of people born in Latin America or of Latin American background) and Asian documented immigrants to be qualified for nonemergency Medicaid services.⁸ The Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996 invoked fears about crime and immigrant criminality to authorize collaboration between immigration authorities and local law enforcement and to expand the list of criminal offenses that are grounds for deportation.

Beyond systems explicitly related to migration and citizenship, societal and policy responses to immigrants provide justification for racist policies in other areas: the economic scapegoating of immigrants justifies the curtailment of public benefits, myths of noncitizen voter fraud justify voting restrictions, and concerns about illegal drug trafficking justify punitive domestic drug policies. Immigration policies are the product of racialized attitudes regarding immigrant “legality” and deservingness as well as “color-blind” approaches that reinforce racial/ethnic inequities. Consequently, immigration policies serve as legally and socially acceptable means to exclude individuals seemingly based on legal status while actually reinforcing other mechanisms of structural racism.

GOING TO THE SOURCES OF RACIAL POWER

In addressing immigration policy as a mechanism of structural racism, it is critical to go beyond immigrant populations themselves and examine the root sources of racial inequality. The US system of racial hierarchy is created by the power of a White-dominant society.⁷ Despite having different histories of migration and trajectories of racialization in the United States, immigrants are “linked by a shared experience of US government oppression.”^9(p51) The public health field should continue to shift its unit of analysis from a focus on racial/ethnic categories to the structures and systems that are the source of power, racialization, and racial inequities.¹⁰

When racial/ethnic categories are used to measure racial/ethnic health inequities, they serve as proxies of racism and experiences of individuals’ racialized positions.¹⁰ This may obscure variations within groups and implicitly reinforce the idea that intrinsic group differences, rather than structures and systems, determine how racism harms health. The public health field can move beyond racial/ethnic categories to measure racialized experiences and inequalities in immigrant populations (bit.ly/3G62VmG). For example, a recent study looked at the types of immigration enforcement that Latinx and Asian immigrants experience (e.g., being racially profiled, being deported or knowing someone who was).¹¹ Not surprisingly, the two groups were found to have distinct patterns of exposure to racialized enforcement encounters, with Latinxs experiencing the greatest extent of enforcement. Yet, the relationship between enforcement encounters and mental health was the same for both groups: each additional enforcement encounter was associated with increased psychological distress for both Latinx and Asian immigrants. Although groups may experience distinct patterns of racialization, it is these experiences of racial discrimination—not intrinsic group differences—that likely drive outcomes. Researchers can shift from solely using racial/ethnic categories to measuring systems, institutions, and manifestations of racism (e.g., enforcement, labor exploitation); practitioners can shift from developing interventions tailored solely to specific racial/ethnic groups to those tailored to address trauma and other harms from racial exclusions (e.g., affected by deportation or workplace abuses).

Public health researchers have begun to shift the focus to systems of racism by measuring immigration policies. As Cerda et al. note, there is a growing body of evidence that anti-immigrant policies are associated with worse immigrant health outcomes.¹² Expanding this level of examination and developing policy interventions are central to dismantling structural racism and can involve incorporating other types of public policies that perpetuate structural racism. For example, a recent policy scan identified racism-related state policies that may influence health, including mandatory minimum sentencing laws, stand your ground laws, and voting restrictions.¹³ Public health researchers can examine additional structures and systems, such as the labor laws that produce weak worker and financial protections for immigrants. Practitioners and advocates can support policy change efforts that address both immigration- and nonimmigration-related policy change. Through these actions, the public health field can study and intervene in policies and institutions perpetuating racial/ethnic health inequities.

ADDRESSING INTERSECTING SYSTEMS

Cerda et al. highlight that improving immigrant health is critical for improving the health of all populations in the United States. Similarly, addressing the mechanisms of structural racism that affect immigrants of color is critical to dismantling structural racism for their US-born children and people of color broadly. Although we agree with Cerda et al. that it is important to address the needs of Latinx and Asian immigrants, a structural racism framework brings needed attention to other immigrant groups because it focuses on intersecting systems, institutions, and practices and how they reinforce one another to harm health.¹⁴ Historical and present mechanisms of structural racism that may seem unique to immigrants (e.g., immigrant policies) work in conjunction with the mechanisms related to other social determinants of health, such as housing, reproductive justice, mass incarceration, and economic inequality. Addressing structural racism mechanisms related to immigrants can contribute to strategies to dismantle these other systems of structural racism.¹⁵ We provide a few brief, nonexhaustive examples of the intersectional experiences of a range of immigrants of color:

• •Undocumented Latinx immigrants experiencing homelessness are uniquely vulnerable to mental health challenges. In a report from Los Angeles County, California, a region with high rates of homelessness, unhoused Latinx individuals were the least likely to receive public benefits compared with other racial/ethnic groups because of factors such as their legal status.¹⁶ Approaching their mental health service needs from a structural racism framework requires that we address racially exclusionary housing policies, labor exploitation and precarious employment, and citizenship policies that intersect to produce housing instability and limit options to obtain mental health services.
• •Although women across the United States contend with abortion restrictions, undocumented women of color living along the US–Mexico border face an additional hurdle to obtaining an abortion: the direct threat of immigration enforcement. The region is dotted with multiple Border Patrol stations, where racial profiling is routine. Whether in California, which continues to allow abortions, or in Texas, which now prohibits it, undocumented women face detection and apprehension if they travel by road to obtain an abortion.¹⁷ Their risks of psychological distress stem from the intersections of sexist, antiabortion policies, citizenship policy, enforcement policies, and racial-profiling practices.
• •Black immigrants are at heightened risk of traumatic encounters with law enforcement and being caught in the US deportation dragnet. Stop-and-identify and stop-and-frisk policies, which allow law enforcement to stop and interrogate individuals, have a disproportionate effect on Black, Latinx, and Black-Latinx citizens and noncitizens because of racial discrimination in policing.¹³ Studies have shown a link between neighborhood stop-and-frisk encounters and psychological distress.¹⁸ Black immigrants are more likely to be detained and deported because of a criminal conviction, not immigration violations, than are non-Black immigrants.¹⁹ Intersecting policing, criminal-legal, and immigration enforcement policies as well as racially discriminatory police practices have produced distinct vulnerabilities among Black immigrants.
• •Asylum seekers face threats to their mental health because of premigration or migration trauma and stress from the extreme precariousness of being granted protected status by the US government. Yet, although all individuals in danger are deserving of human rights, US immigration policy has favored some groups over others. Ukrainian and Syrian refugees have been welcomed as a response to devastating wars overseas. By contrast, asylum seekers from Venezuela and other countries arriving at the southern border have been treated as political pawns in actions akin to the treatment of Black individuals during the Reverse Freedom Rides in the 1960s (bit.ly/3G1PpQV). Haitian asylum seekers were violently turned away by mounted Border Patrol at the Rio Grande in Texas (bit.ly/3tgz4Ae), and others have been denied entry under Title 42, a law from the 1940s that was reactivated for the COVID-19 pandemic.
• •Long-term harms of systemic racial exclusion are evident among Asian immigrants. For example, Southeast Asian youth refugees who arrived in the United States in the 1970s and 1980s were settled in communities that had long faced overpolicing and disinvestment in employment, education, and health resources. They and their families received little mental health support to process the traumas of US-caused wars.²⁰ As a result, some of these youths engaged in criminal activity and were incarcerated. Today, despite being lawful permanent residents and completing their prison sentences, under IIRIRA, the US government has proactively sought to remove thousands of these refugees from the United States.²⁰

These examples highlight that expanding the public health and social services safety net for immigrants is necessary but not sufficient. For example, as Cerda et al. note, worker protections may be ineffective if undocumented immigrants are threatened by employer retaliation. If policy changes are made in only one domain (e.g., mental health care), it will not be enough to dismantle structural racism. Policies that decriminalize immigrants, for example, by providing them with driver’s licenses or limiting local law enforcement’s collaboration with immigration authorities, may lower unmet medical needs for some populations, such as the children of immigrants.²¹ Other strategies can include working to repeal laws such as IIRIRA, advocating to end policies of anti-Black racism (e.g., stop-and-identify, voting restrictions), establishing affordable housing and renter protections, and supporting the long-time reproductive justice efforts of women of color.

ANTIRACIST MULTISECTORAL PARTNERSHIPS

Multisectoral partnerships that change multiple systems are necessary to address the embedded, intersecting systems of structural racism.¹⁵ This requires public health to partner with other sectors, such as housing, reproductive justice, and community investment. As Cerda et al. note, immigrant communities must be key partners in such efforts. Public health researchers and practitioners can partner with and support community organizations that may not be explicitly health care focused but that are engaged in dismantling structural racism. Immigrant-led and -serving organizations have been piecing together community support and funding for a long time to meet the needs of those not served by the US safety net. Supporting and collaborating with immigrant-led organizations that incorporate a structural racism framework into their work, such as Black Alliance for Just Immigration (https://baji.org) and the California Immigrant Youth Justice Alliance (https://ciyja.org), can advance community-centered advocacy, interventions, and policy change that are informed by a deep understanding of the source of racial inequities and the strategies needed to achieve equity.

In working with partners, it is critical that we also examine and address the patterns of racism that are closest to us, being mindful of our own power and prejudices and how they influence our research questions, interventions, and relationships. Health care and social welfare leaders, policies, and programs in the United States have contributed to structural racism. Some public health programs created segregated and unequal services and reinforced racially coded concepts of the deservingness of different groups.²² Interventions that have placed the responsibility for change on immigrants do not address the “fundamental” causes of racism and ultimately reinforce racial health inequities.²³ Scholars and practitioners from immigrant communities and communities of color should (and need support to) be leaders in addressing structural racism in our field.

The work of dismantling structural racism also needs to happen across social (e.g., familial networks, peer networks) and cultural (e.g., houses of worship, cultural organizations) settings where people organize socially and politically. As Latina public health scholars, one White and one Black, our experiences reflect that racism, racial inequalities, and colorism are present in Latin America, not just in the United States, even if the dynamics differ between countries. We are mindful of how racism is perpetuated by the structures and attitudes in these settings. Furthermore, as non-Asian women, we know that we do not have the expertise to speak of the diverse experiences of Asian immigrants and need to build multiracial partnerships to advance racial equity.

As research on structural racism and its effects on health continues to advance, the structural racism framework is a vital tool for informing immigrant health research, policies and interventions, and partnerships. When immigrant health is examined through a structural racism framework, it becomes evident that policies, practices, and attitudes related to immigration are manifestations of structural racism. Addressing the mechanisms of structural racism in immigrant health can contribute to strategies to dismantle the many other systems of structural racism.