AAP Voices Blog

*Editor's note: This is one of a series of "AAP Voices" blog posts highlighting how racism impacts the health and well-being of children, adolescents, young adults and their families. To learn more, see the newly released American Academy of Pediatrics' policy statement, "The Impact of Racism on Child and Adolescent Health."

Wrapping up Rosa’s urgent visit, after I’d diagnosed, treated and educated her about an asthma attack, I review her mother’s answers to our clinic’s social determinants of health screening. Rosa’s mother indicates that she often worries about running out of food, transportation and legal issues.

Since I’ve seen Rosa for primary care visits, I know that she and her family fled from horrific violence in El Salvador 2 years ago when Rosa was 4-years old. She and her mother are among the fortunate 20% who were granted U.S. asylum. Rosa’s grandmother, who cares for her while her mother works two jobs, was not granted asylum and remains unauthorized.

How immigration policy impacts social determinants of health

Rosa has several positive, protective factors in her life that promote resilience during adversity, such as strong family relationships. But I’ve cared for many patients in similar situations to hers, so I brace myself for the inevitable negative impacts of racism, poverty, and immigration policy--all of which are intertwined.

Food insecurity is one of the first problems the screening reveals. Rosa’s mother works two jobs, but the minimum wage in North Carolina is $7.25 an hour. This is not enough to sustain the family, and food runs short.

Rosa qualifies for public benefits, such as Supplemental Nutrition Assistance (SNAP), but the ultimate goal is to get green cards. Immigrants can apply for permanent resident status after being in the United States for at least a year after receiving asylum. Rosa’s mother heard about the “public charge rule,” and even though it doesn’t pertain to her since she has asylum, she still worries how it could affect her chances. So, Rosa’s mother chooses not to accept “handouts” from the government, and her daughter goes hungry when she is not at school.

Access to transportation comes up, affecting other basic needs such as health care. Rosa has missed multiple well child appointments and asthma follow-up visits due to lack of transportation. There is no direct bus to the clinic, so she must take 1 bus to the transportation center downtown, and then a different bus to the clinic. Since clinic visits often last over an hour, this means a 5-hour or more roundtrip. Missing work would mean even less money for basic needs.

Then there’s the constant stress of family separation the family endures. Because Rosa’s grandmother is unauthorized, her family lives with constant fear and anxiety that she will be deported. Her grandmother never leaves the home, so Rosa doesn’t either. They worry constantly that their neighbors, who are not Latino, will call “la migra” on them because they speak Spanish only and have been called “spics.” Rosa’s mother needs legal assistance for the grandmother’s immigration case.

The inequities Rosa and her family face because of their race, ethnicity and country of origin are not unique. Although they are largely preventable with investments in policies to address immigration, poverty and the social determinants of health, policy solutions remain elusive in our current political climate.

“Rosa has several positive, protective factors in her life that promote resilience during adversity, such as strong family relationships. But I’ve cared for many patients in similar situations to hers, so I brace myself for the inevitable negative impacts of racism, poverty, and immigration policy--all of which are intertwined.”

Developing resources & community partnerships

As pediatricians, however, there’s a lot we can do to help families like Rosa’s. It begins with the care and resources we provide. I’ve built a trusting relationship with Rosa and her family during many visits, for example, in which I provide culturally effective, team-based care as her primary care provider. Rosa’s family feels safe within her medical home and has access to many services she is willing to utilize. In addition to screening for social determinants of health, our clinic provides resources and referrals to community-based support organizations with which we’ve built strong partnerships.

We’ve developed a food pantry coordinated by a “food pharmacist” who meets with food-insecure families. The coordinator provides the family a grocery bag of non-perishable foods, connects them to governmental services such as Women, Infants, and Children, provides referrals to local emergency food pantries we partner with, and calls families to follow up with any unresolved issues. We also have a community garden housed onsite, which provides patients and their families access to fresh produce.

Through grant-funding, we are able to provide emergency transportation vouchers for families who have difficulty making it to appointments. We have an on-site medical-legal partnership to assist families with legal concerns; for those with immigration-related issues, we established grant-funded pro-bono consultations with local immigration lawyers.

To help mitigate the negative psychological impacts of trauma and toxic stress, our onsite pediatric behavioral health provider meets with families who screen positive for mental health issues. Our clinic also houses an early childhood developmental program, Imprints Cares, that offers home visits to at-risk families with infants and children up to 5 years old.

As members of our community, we’ve rallied around newly arrived immigrant and refugee residents with the support of the city. We’ve formed coalitions such as the Refugee Health Collaborative with the Department of Public Health, the Building Integrated Communities Stakeholders Committee through the Human Relations Department, and the Mayor’s Partnership for Prosperity, which engages community members in tackling poverty. The state’s Health Opportunities Pilot will provide tools, infrastructure, and financing to integrate non-medical services directly related to improved health outcomes into an innovative, whole-person centered and well-coordinated system of care.

By leveraging the strengths of multiple service delivery systems within the community, practicing culturally effective medical care, and implementing clinic-based programs addressing the social determinants of health, immigrant patients like Rosa and her family will be better equipped to confront the daily challenges of racism and poverty.

But that doesn’t mean we can stop working toward comprehensive policy change. Through ongoing advocacy efforts and engagement with legislators as part of the American Academy of Pediatrics Council on Community Pediatrics, pediatricians can continue to support policies that improve the health and well-being of immigrant children.