Immigration is a major historical, yet current influence and integral part of how nations continue to grow and change in population and diversity. M. Fix and J. S. Passel (1994) list the principal goals of U.S. immigration policy as: social, economic, cultural, moral, and national and economic security (includes protection from infectious and animal-borne diseases, environmental hazards, food safety, terrorists, and various criminal acts). Canadian and European policies encompass similar goals, but with greater emphasis on the economic impact of immigration. In 1999 over 16 million legal immigrants in Western Europe earned more than $460 billion. However, despite the projection indicating that European countries face a dramatic population decline over the next 50 years, many European countries want to restrict immigration on the basis of economic reasons, including the fear of exacerbating the already significant problem of unemployment. Immigration policies are the responsibility of national governments, while the policies regarding how countries deal with immigrants are shared by the various levels of government—national, state, and local.
At the federal level in the United States, for example, several agencies play key roles in developing and implementing national immigration and immigrant policies. The principal immigration agencies are: the United States Department of Justice Immigration and Naturalization Service (INS), which is responsible for enforcing the laws regulating the admission of foreign-born persons(i.e., aliens) to the United States and for administering various immigration benefits, including naturalization and resettlement of refugees; and the Department of Treasury U.S. Customs Service, which is the primary enforcement agency protecting the nation's borders. Other federal agencies deal more directly with the public health dimension of immigration and immigrants. Although many countries have organizations dealing with immigrants and immigration issues, there are international agencies that act as important brokers regarding migration among countries. The International Organization for Migration (IOM) is an intergovernmental body that is committed to the principle that humane and orderly migration benefits migrants and society. Since 1951, the IOM has acted with member countries (currently 79) to assist in meeting operational challenges of migration, to advance understanding of migration issues, to encourage social and economic development through migration, and to uphold human dignity and well being of migrants.
The United Nations High Commissioner for Refugees (UNHCR) is another international agency which, since 1951, has played a significant role in responding to the world's growing refugee predicament. As one of the world's principal humanitarian organizations, the UNHCR provides international protection to refugees and seeks durable solutions to their plight. For the year 2000, there were about 22.5 million refugees and other persons of concern to the UNHCR.
HISTORY AND DEMOGRAPHICS
Immigration policies have directly influenced the demographic composition of the immigrating populations over the lives of the nations. The first immigration office in the United States and Canadian federal governments were created in the nineteenth century by laws intended mainly to encourage immigration. Later, the U.S. Immigration Act of 1891 provided for deportation of aliens living unlawfully in the country. About this same time, in 1882, the U.S. Congress asserted the first broad federal regulatory power regarding immigration by passing the Chinese Exclusion Act, which suspended immigration of Chinese laborers for ten years. In Canada, although there was no law passed to exclude any particular group of immigrants, careful procedures were developed to ensure most applications submitted by black people were rejected. From the late nineteenth century to the year 2000, most North American, European, and Australian immigration policies have shifted from a focus on qualities of individuals(e.g., excluding illiterates, criminals, those with illnesses) to a focus on countries of origin with a more inclusionary focus using preference categories, to a sharpened humanitarian approach in admitting those in need (such as refugees) through permanent and systematic assessments. In European countries, various approaches for integrating immigrants are at work. Germany has developed special institutions and programs for foreigners, while France tends to stress general rather than foreigners-only programs. The European Union recognizes that immigrants are needed for demographic and economic reasons.
Census data indicate that the percent of foreign-born persons in the total U.S. population has waxed and waned from a high of 14.8 percent in 1910 to a low of 4.7 percent in 1970. In July 1999, the foreign-born resident population estimates totalled about 25.8 million, or about 9.5 percent of the total U.S. population. Likewise, Canada's peak year for immigration (1913) saw the arrival of about 400,000 people. Its 1996 census showed a continued growth in immigration with 17.4 percent of Canadian residents being first-generation immigrants. From 1990 to 1999, the United States foreign-born population increased. Hispanics increased from 8 to 11 million persons, and the Asian and Pacific Islander groups increased from4.5 to 6.3 million. More than 60 percent of the Asian and Pacific Islander populations in the United States and about 35 percent of Hispanics are foreign-born.
These statistics reveal how changes in immigration policies, especially within the past fifty years, have influenced the makeup of the foreignborn populations in the United States. For France, there have been several immigration priority shifts over the years. Initially priority was given to members of France's colonies, subsequently, to Italians, Spaniards, Portuguese, and, more recently, to North African guest workers. A shift of immigration priorities also occurred in Canada when, after its 1976 Immigration Act was passed, immigrants from Africa, Asia, the Caribbean, and Latin America were welcomed.
The late nineteenth century and the early twentieth century provided a different country-of-origin profile for immigration to the United States. Since 1820, Germany has been the greatest source of immigrants to the United States, with Mexico ranking second, Italy third, and the United Kingdom and Ireland a close fourth and fifth, respectively. Changes were evident in 1996 when the country-of-origin profile for immigration showed that of the top ten nations, four were Asian nations, three Latin American nations, two from the former Soviet Union, and one from the Caribbean. The United States Immigration Reform and Control Act of 1986 provided an amnesty for undocumented persons living in the United States under certain conditions, which resulted in about2.8 million persons attaining legal status—the majority of whom were Hispanic. The 1996 count used by the INS for "illegal alien populations" or undocumented persons is about 5 million, with about 2.7 million estimated to be from Mexico. Other countries in Europe indicate that 300,000 to 1,000,000 "unauthorized immigrants" reside within their borders.
Immigrant populations in the United States from the Asian and European countries have more years of education than immigrants from Latin American countries. Further 1999 estimates of the average age of foreign-born racial and ethnic groups range from seven to eleven years older than the U.S. total population estimates for the respective groups. The occupations of immigrants depend on their education and their proficiency in speaking English. It was estimated that in 1990 about 40 percent of immigrants were either operators/laborers/fabricators or service workers. Immigrants contribute to the U.S. economy not only in terms of labor force participation rates but also in terms of taxes paid and earnings spent for goods and service on their local economies. On the other hand, in 1997, the unemployment rates for immigrants were much higher in France than for French nationals. The French nationals' rate was 12 percent compared with 31 percent for immigrants from non-European Union countries and 50 percent among North Africans.
Geographic distribution of the foreign-born within the United States from the 1990 census indicates that most live in the West and are from Mexico. Immigrants settle and reside mainly in metropolitan areas such as New York City, Los Angeles, and Miami; this is also consistent with the living patterns of Hispanic and Asian populations in the United States. Projections of the immigrant populations by the Census Bureau at the low, middle, and highest series indicate that the largest growth will be in the Asian and Pacific Islander populations over the next fifty years. Using the 1990 base for population projections, the Census estimates that by the year 2045, foreign-born populations will grow to about 13.5 percent of the total population, compared to 9.5 percent in 1999. The distribution of immigrant ethnic groups in Canada shows people from the British Isles as the majority throughout Canada with the exception of Quebec where the French dominate. The West and prairie provinces include about 15 percent German and significant numbers (9 to 11 percent) of Ukrainians.
IMPLICATIONS FOR PUBLIC HEALTH
Although immigration policies are complex, much of the work of responsible public health professionals and organizations is to consider how best to serve the immigrant populations who arrive. As noted above, there are several public health agencies in the United States responsible for the health of the entering populations. Other nations and international organizations also help with caring for the education, social, and health needs of immigrants. For refugees, in particular, the resettlement process in the United States includes the federal agency working with local providers to ensure health services are provided. Other than refugees and asylees, immigrants must ensure that they do not become a "public charge," that is, dependent on the government for subsistence. Based on determinations of INS in consultation with the Department of Health and Human Services, United States federal health services programs can be provided to immigrants without being considered "public charges." There are other restrictions to public benefits that are part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which restricts access by some legal immigrants to certain programs and denies access by undocumented/unauthorized immigrants to many government funded programs. Federal and state programs affected under this law include Medicaid, the Children's Health Insurance Program, Temporary Assistance for Needy Families, Supplemental Security Income, and food stamps.
For public health purposes, the state's restriction of certain public benefit programs must not inhibit the public health system in serving immigrant populations with interventions and services that target at-risk populations. Knowing the populations within the community is a fundamental requirement in public health. Assessments of immigrant populations must take into account the country of origin and its socio-political context, language use and level of language proficiency, age and educational profile, cultural nuances including specific gender practices and protocols, time in the country and familial ties, particular health practices and beliefs that may be common to the population, social and religious beliefs and practices, and the economic conditions of employment. Such assessments then include not only a quantitative epidemiological approach, but also a qualitative ethnographic inquiry as complementary data.
Policies developed for public health systems are critical in addressing the particular characteristics and needs of immigrant populations. Being consistent in serving the populations establishes a trusting environment for newly arrived and foreign-born populations who may have emigrated from countries where governments were not trustworthy. In keeping with the United States Healthy People 2010 report's second goal of eliminating health disparities, policies will also need to be flexible and allow for interpretation in the field.
Providing the proper interventions and services through culturally competent systems becomes a major challenge for the public health community, not just the public health government agencies. Generally, immigrants are not familiar with the variety of places (both private and public) from which services and promotion of healthy practices are derived. Getting to know the different sources of services is much more complex than immigrant populations may have experienced in the past. (Moreover, it is not unlikely that in some countries the systems are such that even the native-born populations are still unfamiliar with how their public health systems work.) Such coordination requires collaborative trust among providers and their respective organizations, and will help to build more confidence in the use of the system by the immigrant populations.
As a final point for the public health community in refining experiences with immigrant populations, there is the need to keep up with what potential public health issues are occurring globally, nationally, statewide, and, of course, locally. Experience has shown that refugees and other immigrants can quickly be placed in a community due to some type of international disturbance. Keeping informed of immigrant populations as part of the community allows for better decisions on what health improvements may be needed, and what actions should be taken when more immigrants arrive.
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