Book Review

Handbook of Immigrant Health

N Engl J Med 1999; 340:972March 25, 1999

Article

Handbook of Immigrant Health
Edited by Sana Loue. 654 pp. New York, Plenum Press, 1998. $115. ISBN: 0-306-45959-0

Interest in the health issues affecting immigrants has grown over the past 10 to 20 years, as the number of immigrants in the United States has increased dramatically — from under 10 million in 1970 to almost 26 million in 1997. Although a few states continue to have unusually high concentrations of immigrants — almost 25 percent of California's residents are foreign-born — even states without a recent history of immigration, such as Iowa, are now experiencing an influx of workers from Mexico and elsewhere. Thus, there are few regions of the country where health professionals can safely ignore this subject. The Handbook of Immigrant Health has the scope and depth to serve well as either the only book about the topic on one's shelf or as the cornerstone of a large and specialized collection.

The book contains a superb set of review articles on the behavioral, social, and cultural issues most pertinent to immigrant health. Common themes emerge from the 30 diverse chapters. Perhaps the most important one is that most immigrants come from cultures that are substantially less individualistic and dualistic than that of the United States. As a result, many of our assumptions about behavior with respect to health and the treatment of illness need to be modified in order for us to understand the health issues of immigrants. A second recurrent theme is that although cultural differences underlie many of the distinctive features of this field, there are a number of political, economic, and social factors that must also be taken into account. These themes are illustrated in summaries of the research literature, case studies, and extensive epidemiologic data.

Although the chapters are not explicitly organized into sections, there are several naturally occurring ones. The first chapters cover research-oriented topics, such as how to measure acculturation, indicators of access to care (which uniformly show problems for immigrants), and how questionnaires on health status, such as the Medical Outcomes Study Short-Form Health Survey, can be adapted to non-Western people.

Another group of chapters is clearly designed to inform clinical practice by providing discussions on such issues as the paths that immigrants are likely to take in seeking care for health problems, the roles that members of immigrant families often have in illness and healing, and ways to gain access to immigrant communities. Several of the chapters include discussions of the challenges of communicating across language and cultural barriers, showing in particular that simply being bilingual does not necessarily result in effective communication. Two chapters cover nonmedical healing practices and folk illnesses; the one by O'Connor offers an insightful framework of useful categories of nonbiomedical health beliefs, illnesses, and healing practices. Two chapters on health education suggest modifications that are needed to make common theories of behavior with respect to health applicable to immigrants and offer some case studies of successful programs.

Several chapters focus on specific groups of immigrants, such as refugees, Hispanics, Asians, and Africans. Most of these chapters provide a comprehensive epidemiologic overview of the particular group, summarizing the research on key diseases, risk factors, and health behavior. The health status of Mexican immigrants is called an epidemiologic paradox, because their economic status, educational status, and access to health care are similar to those of African Americans, but their birth outcomes (and mortality profile) are substantially better. This finding points to favorable characteristics common to many immigrants: lower rates of smoking and drug and alcohol abuse, better diets, and more social support. Although most chapters dwell on the problems immigrants face, it is important to remember that immigrants also bring remarkable strengths with them. The chapter on refugees provides useful advice on special topics that should be covered when health care providers take a history and develop treatment plans.

Specific health problems that immigrants are likely to face, including mental illness, drug and alcohol abuse, and violence, are the topics of another group of chapters. An extensive chapter on infectious diseases provides overviews of many infectious agents and of the epidemiologic features, clinical presentation, diagnosis, and treatment of a large number of syndromes found primarily in developing countries. Data presented on the prevalence of cancer document variation among persons in their countries of origin, immigrants in the United States, and persons born in the United States, suggesting environmental and lifestyle risk factors. The interaction of culture with reproductive health raises a number of issues, some of which are discussed in other chapters, such as female circumcision and infectious diseases not common to the United States. For topics on which there are few data on immigrants, such as occupational injury and domestic violence, the chapters provide useful generic discussions of key issues.

The quality of the contributions to this book is, with few exceptions, excellent. By presenting comprehensive syntheses of the literature, this collection offers valuable information and insights of use to clinicians, researchers, and policy makers.

Steven P. Wallace, Ph.D.
UCLA School of Public Health, Los Angeles, CA 90095-1772