Critical Perspectives on Racial and Ethnic Differences in Health in Late Life (2004) / Chapter Skim
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7 Immigrant Health: Selectivity and Acculturation
7 Immigrant Health: Selectivity and Acculturation
Pages 227-266
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From page 227... ...
Ethnic health disparities are inherently linked to immigration because ethnic identities are traced to the country of origin of an immigrant or his or her ancestors. The average healthiness of the original immigrants, the diversity in health status among immigrants, and the subsequent health trajectories following immigration both over the immigrants' lifetime and that of their descendants all combine to produce the ethnic health disparities we observe at any point in time.
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From page 228... ...
Two of the more central questions that have emerged involve the mechanisms shaping health selectivity and the determinants of health trajectories following immigration. With this in mind, the next section outlines some simple theoretical models of health selectivity of immigrants and their subsequent health trajectories following immigration.
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From page 229... ...
The picture is quite different when disease prevalence rates are used instead as the health index. Across all conditions and in every age category listed in Table 7-2, the foreign born have much lower rates of chronic conditions than the native born.
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From page 230... ...
born 9.1 7.3 9.9 13.1 9.7 Foreign born 2.4 5.8 6.3 7.4 5.3 SOURCE: Calculations by authors from the 1996 National Health Interview Survey. Note that because questions on specific chronic conditions were given to one-sixth of the sample, the number of observations in this table are approximately one-sixth of those in Table 7-1.
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From page 231... ...
A cross-sectional age pattern inherently cannot separate across-cohort differences from those that represent the pure effects of aging or staying longer in a location. Compounding this problem, there are nontrivial rates of emigration from these immigrant cohorts, and any health selectivity associated with such emigration would add more complexity.
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From page 232... ...
By appropriately arraying the data by year since immigration and by age, one can in principle track cohorts as they age. This stratification is the basis of Table 7-5, which lists self-reported health status by time TABLE 7-4 Rates of Chronic Conditions of New Immigrants 0-5 6-10 11-15 All 25-44 50+ All 25-44 50+ All 25-44 50+ Hypertension 6.3 2.7 31.8 5.1 3.5 17.0 7.4 3.2 27.6 Diabetes 1.4 0.8 6.1 2.1 1.0 8.2 1.9 0.9 8.0 Cancer 0.2 0.1 1.3 0.1 0.0 1.2 0.2 0.1 0.8 Lung disease 2.1 1.9 3.7 3.2 3.2 5.9 3.2 3.2 3.8 Arthritis 5.3 2.8 23.1 5.3 2.1 24.7 7.0 2.5 26.3 Heart disease 3.7 1.9 18.0 3.7 1.6 11.5 2.6 2.7 14.5 Asthma 1.1 1.3 1.9 2.6 2.7 3.1 2.3 2.2 2.8 NOTE: For each condition, the numbers of observations are about 1,300 to 1,400 in the "All" column for each of the times since immigration, about 800-900 for the 25- to 44-yearold age group and about 200 for the 50+ age group.
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From page 233... ...
However, there is some evidence of a greater movement of recent immigrants into the fair or poor category. When we compare the native born to those whose reported 1991 time of arrival was 6 to 10 years ago, if anything immigrant health deterioration may be less than the native born.
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From page 234... ...
Rather, health selection of migrants involves a comparison between the health of migrants and stayers in the sending countries at the time of immigration. This comparison would be extraordinarily difficult given the number of sending countries and the state of health data in most of the sending countries.
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From page 235... ...
Instead, we focus our review on that part of the literature that deals centrally with the main issues of the initial health selectivity of immigrants and the subsequent health trajectory following immigration. Epidemiology has a long tradition of using migrant studies to isolate environmental effects on health.
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From page 236... ...
Traditional Japanese culture is more characterized by group cohesion and social stability, which may be stress reducing and thus protective in reducing heart disease. Marmot examined health outcomes of Japanese living in and around the San Francisco Bay area, stratified by the degree of adherence to Japanese culture.
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From page 237... ...
There were no differences in mortality from coronary heart disease among the three cohorts and only weak evidence that diet is related to the development of coronary heart disease. In addition to using migrant samples to test the impact of differential environmental exposure, the second issue that has loomed large in the epidemiological studies concerns the health selection effect.
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From page 238... ...
With the exception of diabetes, Hispanic age-adjusted death rates are actually lower for all diseases than those of non-Hispanic whites. The only group that outperforms Latinos on these measures is Asians/Pacific Islanders, whose overall lower mortality rate is due principally to low rates of death from heart disease.
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From page 239... ...
Cardiovascular diseases are known to be sensitive to prolonged exposure to high levels of stress, so that relatively high rates of heart disease among the foreign born associated with length of stay may be indicative of such a mechanism. More recently, heart disease has played an increased role in these studies.
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From page 240... ...
Although this concern is much diminished today, tuberculosis tests and medical exams are required before admittance to permanent residence in the United States. THEORETICAL ISSUES There are two perennial themes to the literature on migration and health outcomes -- the nature of the health selectivity of international migrants and the impact of migration on the subsequent health trajectory of migrants.
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From page 241... ...
Similarly, migrants from countries with lower skill prices relative to those in the United States will be less positively selected on migrant health. Finally, when skill transferability is lower, migrants will more positively select on health.
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From page 242... ...
The data contained in Table 7-7 do suggest that the migrant health selection effect may be strong, but there is no control for duration of stay in the United Kingdom. As a first step toward gauging the importance of health selectivity, Table 7-9 ranks countries by numbers of legal male migrants to the United States in 1995, and then provides for each country the levels of male life expectancy and the probability of a male dying between ages 15 and 59.
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From page 243... ...
The typical Indian migrants to the United States would clearly not expect such a life expectancy either in India or in the United States. Table 7-9 also suggests that the extent of health selection varies considerably across sending countries.
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From page 244... ...
has computed male life expectancy by ethnic group for the native born and foreign born in the United States. Her data demonstrate TABLE 7-10 Comparisons of New Legal Immigrants with Life Expectancy in Country of Origin Country of % in Excellent % in Fair % with any % with any Origin Male Life or Very Good or Poor Chronic Serious Grouping Expectancy Health Condition Condition Condition 1 72.3 57.1 14.1 20.6 7.0 2 67.5 43.4 29.4 23.9 6.4 3 58.7 52.9 22.1 23.4 6.9 NOTE: The three country groupings are based on the list of 17 countries in Table 7-9, ordered by levels of male life expectancy.
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From page 245... ...
This must mean that health selection among Asians is very large or that the United States is a much healthier place to live than the typical Asian sending country. Although Asian life expectancies are lower in the second generation, they remain much higher than in the Asian sending countries.
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From page 246... ...
, which are typically unobserved by the researcher, have played an important role in contemporary research on this topic. For example, Rosenzweig and others have argued that the existence of these unobserved background factors that can often be traced to early childhood may seriously bias estimates of this production function.8 In this framework, health changes over the life course and the trajectory of these changes are the result of the stock of health in the time period t1, Ht , depreciation over the previous time period, and investments to 1 improve health in the previous time period.9 The current inputs and behaviors chosen are investments that produce increments to the stock of health.
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From page 247... ...
Because there are more than 100 different sending countries, it indicates that individual studies such as those of Japanese immigrants are
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resident. Rather, the effect on the health of an immigrant changing countries involves a comparison of the health trajectory of an immigrant in the receiving country with the health trajectories of "similar" people in the sending countries.
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From page 249... ...
This age pattern among legal immigrants is additional evidence that the nature of health selection is very different among older immigrants. Table 7-13 lists rates of chronic conditions for respondents in the NISP.
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From page 250... ...
In fact, rates of contact with Western medicine among new legal TABLE 7-13 Rates of Chronic Conditions of New Legal Immigrants NIS Native Born 0-5 All 25-44 50+ All 25-44 50+ All 25-44 50+ Hypertension 10.8 4.6 40.6 16.9 6.0 33.3 6.3 1.4 31.6 Diabetes 2.5 0.6 13.3 4.1 1.5 8.9 1.4 0.0 3.4 Cancer 0.7 0.6 1.8 2.3 0.6 5.9 0.2 0.1 1.3 Lung disease 1.9 1.4 4.6 9.7 4.1 12.4 2.1 2.0 0.0 Arthritis 7.4 3.1 27.3 16.9 6.3 36.3 5.3 3.1 21.4 Heart disease 3.0 1.0 15.1 8.9 5.9 19.9 3.7 0.0 19.9 Asthma 3.4 2.8 3.6 5.4 6.0 5.0 1.1 1.3 0.0 SOURCES: Native born and 0-5 from NHIS and from New Immigrant Pilot Survey. For number of observations, see Table 7-12.
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From page 251... ...
Born Hypertension 3.9 7.7 38.1 35.7 Diabetes 1.4 1.9 7.1 10.2 Cancer 0.2 0.8 1.1 6.7 Lung disease 2.7 10.4 4.7 13.2 Arthritis 3.2 7.3 31.2 40.1 Heart disease 2.7 6.1 23.9 26.1 Asthma 2.3 5.9 1.4 5.3 immigrants are quite high; 62 percent of the new legal immigrants said they had seen a doctor during the past year. Even among those who had such contact, reported rates of chronic conditions are much lower among new immigrants than among the native born.
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From page 252... ...
Panel B of Table 7-16 illustrates this diversity by visa status by listing prevalence rates for the more common chronic conditions. As before, TABLE 7-16 Diversity of Immigrant Health Outcomes by Visa Status A
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To this point, our data on the health status of new legal immigrants has concentrated on when they arrived. The question of what happens subsequently has absorbed much recent research on immigrant health.
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In general, immigrant health is quite good and it appears to improve over time, at least in the short run.
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Both models rely on data obtained from the New Immigrant Pilot Survey, which was described in detail in the previous section. We first present our analysis of health selectivity of migrants and conclude this section with a simple model of short-run health changes following immigration.
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From page 256... ...
In terms of the observable correlates of skill prices, among workers residing in countries with the same output per worker, those workers residing in countries where workers have higher average skill levels receive lower skill prices, while among workers in countries with the same average worker skill levels, those in countries with higher output per worker will receive higher skill prices. Given immigrant skill heterogeneity and selectivity due to home country skill-price variation, these results imply that immigrants from countries with high output per worker and with low average levels of schooling will have the highest skill levels and best health among immigrants with identical own schooling levels.
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Variable/Estimation Procedure GLS Ordered Logit Home country characteristic Ln (real GDP/worker)
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From page 258... ...
immigration barriers or costs and should, given skill prices, be disproportionately sending countries for low-skill and less healthy immigrants. Worker attributes included in these models include own schooling measured in years, number of years in the United States because some of these immigrants obtained their green cards while living in this country, a quadratic in age, sex (an indicator variable set to one for women)
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In contrast, there appears to be no relation between country-specific average life expectancy and home country earnings. This may reflect two offsetting forces.
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From page 260... ...
In sum, the results in Table 7-18 indicate that there exists systematic variation in the skill and health selectivity of immigrants to the United States that in large part conforms remarkably well with the theoretical predictions outlined earlier. In particular, the country-specific factors that positively select on the skills of new immigrants also appear to positively select on their health status.
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From page 261... ...
. Thus, even though the model estimated in Table 7-19 only predicts short-run health changes, the persistence of these large economic gains over the long term makes one suspect that on this mechanism at least health improvements might also persist.
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From page 262... ...
Currently available immigrant samples are, at best, representative samples of the currently resident foreign-born population -- those members of past immigrant cohorts who remained in the United States. Because we know little about the nature of the health selection of those who emigrated, it is impossible to deduce what health trajectories were for the typical immigrant.
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From page 263... ...
These issues involve the magnitude and mechanisms shaping health selectivity and the determinants of health trajectories following immigration. Health selection -- the propensity of immigrants to be much healthier than a representative person in the sending country -- is a quantitatively important phenomenon that is fundamental to understanding the most basic patterns that emerge about immigrant health.
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From page 264... ...
One of the consequences of this strong health selection effect is that it makes current evidence of health trajectories following immigration very problematic. For example, the general theme in the literature appears to be that immigration to the United States may have deleterious health consequences.
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From page 265... ...
Another extension would concern the initial and subsequent health of minor children who accompany their parents in the migration process. The extent of health selection is probably muted for minor children because the correlation in health of migrant parents and migrant children is far from perfect.
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From page 266... ...
. Acculturation and coronary heart disease in Japanese Americans.
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