Monday, October 9, 2017

By Laura Hedli

Consider a six-year-old boy who is anxious and has trouble focusing in school. What if the root cause is unrelated to the boy’s cognitive functioning, but instead has all to do with the daily fear of not knowing whether his mother or father will be gone when he gets home from school?

Fernando Mendoza, MD, MPH, knows that providers rarely ask questions with that sort of candidness. “We don’t ask about politics. We don’t ask about religion. When I’m in clinic and I have a situation like this and I get a feeling of what’s going on, I ask the parent about who’s in the house, where they live, where they work,” he says. “The question I need to ask now is: ‘What’s your status? How do you feel about that?’”

With President Donald Trump’s order to end the Deferred Action for Childhood Arrivals (DACA) program, which grants freedom from deportation to 780,000 undocumented individuals who were brought to the U.S. by their parents, this concern has been amplified for children with a DACA parent. The intergenerational effects of ending DACA have been largely left out of the debate, and the problems are much more pervasive given the estimated 4 million children with at least one parent who is undocumented and not protected under DACA. In California, 12% to 17% of all children in the state are estimated to fall into this category, according to a 2016 report by the Migration Policy Institute. Compared to other children in the U.S., those with an undocumented parent are at increased risk for lower preschool enrollment, language gaps, poverty, and reduced socioeconomic mobility.

Stanford’s location in the Bay Area offers a prime opportunity to study immigrant children and families. In Santa Clara County, it is estimated roughly two-thirds of children are growing up in households with at least one parent who wasn’t born here.

How can we understand the stresses, the health, the futures of these children? How do we ensure they are successful?

For Dr. Mendoza, the Child Health Research Institute (CHRI) is enabling him to find answers through collaboration with experts who have different training backgrounds and perspectives. Dr. Mendoza is the primary investigator on a CHRI Transdisciplinary Initiatives Program (TIP) grant for understanding the health and well-being of children in immigrant families in California, where researchers will explore the impact of federal, state, and local policies on health outcomes.

The grant is active through 2019 and its Co-Investigators bring expertise in immigration policy, survey methodology, data collection, and statistics. Co-Investigators include Political Science Professors Jens Hainmueller, PhD, and David Laitin, PhD, Sociology Associate Professor Tomás Jiménez, PhD, and Executive Director of Stanford’s Immigration Policy Lab Duncan Lawrence, PhD. Interactions among team members shape the development of research questions.

Dr. Mendoza says, “Our grant builds an infrastructure for academic excellence among people who have a lot of expertise, but would be otherwise in silos if we didn’t have these funds to make bridges for collaboration. That, I think, is the basis of good research—developing a way to look at a problem from different perspectives, thus bringing us closer to reality than if it’s just one view.”

Specifically, researchers are investigating the effect of policies on health care utilization and health outcomes of immigrant families and children. The team is looking at DACA as well as two other California policies: AB60, a statewide policy that allows undocumented immigrants to receive driver’s licenses, and SB4, another statewide policy, modeled off of local county policies, that extends Medi-Cal coverage to all children in California regardless of documentation status.

Dr. Lawrence says the goal is to measure the returns on those types of policies. “There has been plenty of focus on the public costs of programs for immigrants, such as extending health insurance, but the benefits haven't been fully measured and explained to the same extent. Momentous decisions are being made without the full picture,” he says, noting that he became interested in immigration issues after working as a medical interpreter in Wyoming. He was struck by the considerable barriers that non-English speakers encounter when they interact with the U.S. medical system

This CHRI TIP grant builds upon prior work done by the research team, led by the Stanford Immigration Policy Lab and funded by the Russell Sage Foundation. The results, published in Science and based on Medicaid data from Oregon, showed marked reductions in the diagnosis of adjustment and anxiety disorders in children whose mothers were protected from deportation under DACA as compared to those whose mothers were not eligible for DACA, (3.3 vs. 7.8 percent). The takeaway is that immigration legislation has the capacity to reduce health disparities in America.

Indeed, Dr. Mendoza stresses the importance of receiving Stanford CHRI funding to continue this work in this area. Although the National Institute of Minority Health and Health Disparities has announced grants for studies on immigrant populations, it has one of the lowest budgets among the 27 NIH Institutes and Centers.

The unrestricted funds from CHRI are allowing the group to expand the focus on the research beyond DACA. Data sources include the California Health Interview Survey, National Health Interview Survey, and de-identified Medicaid claims provided by the California Department of Health Care Services. One of the more ambitious elements of the grant, especially given the contentious political climate, is the aim to conduct in-depth interviews with immigrant families, both documented and undocumented. Dr. Jiménez heads up this qualitative piece. If the data shows that these policies impact immigrants’ health outcomes, the how and the why still need to be accounted for. The interviews will help tell the stories behind the legislation.

“As academic institutions, we know our role in trying to save a child who has a rare disease; however, what is our role in dealing with a situation that can significantly affect one out of every six children in our community?

“You can think of California in some way as the leader in experimenting with all different types of policies to help integrate immigrants,” says Dr. Lawrence. “That is a huge learning opportunity for other policymakers all throughout the U.S.” For instance, states and localities have a certain degree of latitude in choosing how they comply with Immigration and Customs Enforcement (ICE) requests. Local communities can work to create a space where its residents feel safe to call the police to report an emergency, or take their children to a doctor’s appointment without the fear of deportation.

Still, the future remains indefinitely uncertain for the estimated 4 million children who have at least one parent who is undocumented.

The Department of Homeland Security confirmed that all issued DACA and work permits will remain valid until their expiration date. The United States Citizenship and Immigration Services (USCIS) said it will process requests for a two-year renewal of DACA permits that are expiring between now and March 5, 2018 as long as they were received by the deadline of October 5. However, USCIS did not directly notify DACA recipients eligible for renewal about this timeline.

Trump has left it up to Congress to decide the fate of the DACA program. Congress has proposed several bills to protect this group of young immigrants, most notably the bipartisan DREAM Act. Legislation would provide a pathway to citizenship for DACA recipients, and the effects on the children of those DACA recipients could be dramatic and lead to healthier communities.

Dr. Mendoza believes we are at a critical juncture where we have the chance to do the right thing. He recently wrote an Op-Ed for The Sacramento Bee asking Americans to consider the multiple perspectives involved, rather than just their own, when it comes to immigration and America’s future.

“As academic institutions, we know our role in trying to save a child who has a rare disease; however, what is our role in dealing with a situation that can significantly affect one out of every six children in our community?” he says, referring to the children living households with undocumented parents in California. “There’s no disease that impacts this many children. Stanford has the tremendous opportunity to lead the country in thinking about immigrant children in its efforts in health care, education and research.”

Laura Hedli is a writer for the Division of Neonatal and Developmental Medicine in the Department of Pediatrics and contributes stories to the Stanford Child Health Research Institute.