Defining new communities: a challenge for immigrant health

 

Delimitando nuevas comunidades: un reto a la salud del inmigrante

 

Carlos Ulises Decena y Michele G. Shedlin

 

Center for Drug Use and HIV Research/Institute for AIDS

 

Abstract

Efforts to reduce HIV/AIDS vulnerability among U.S. Hispanics/Latinos can benefit from conceptualizing immigrant populations in ways that reflect their composition, social dynamics, economic and health status and permanency. This study employed qualitative methods to identify and describe HIV/AIDS and other health vulnerabilities among recent immigrants to the New York area from Guatemala, El Salvador, Honduras, the Dominican Republic and Mexico. Qualitative data collection involved: a) individual interviews (n = 51); b) 11 focusing groups (n = 86); c) key informant interviews (n = 26) and one focusing group with advocates and providers in health and social services; and d) ethnographic observation. Results indicate that migration and living conditions in receiving locations contribute to new immigrants' disconnection from a sense of "community" that may have negative effects on their physical and mental health. Data support the conclusion that public health policies and programs need to reach some consensus in defining these evolving immigrant "communities" in order to determine and provide culturally appropriate and effective prevention interventions.

Key words: migration, inmigrant populations, hispanics population, vulnerabilidad, HIV/ AIDS, Nueva York.

 

Resumen

Los esfuerzos por reducir la vulnerabilidad hacia el VIH/Sida entre los hispanos en Estados Unidos pueden beneficiarse de desarrollar conceptos para definir poblaciones de inmigrantes y para analizar con mayor precisión su composición demográfica, dinámicas sociales, condiciones económicas y de salud y planes de permanencia en las áreas de residencia. Este estudio utilizó métodos cualitativos para identificar y describir vulnerabilidad al VIH/SIDA y otras condiciones de salud entre inmigrantes recientes al área de Nueva York desde Guatemala, El Salvador, Honduras, República Dominicana y México. Los métodos de compilación de datos incluyeron: a) entrevistas individuales (n = 51);b) 11 grupos de enfoque (n = 86); c) entrevistas (n = 26) y un grupo de enfoque con informantes claves, escogidos entre activistas comunitarios y proveedores de servicios sociales o de salud; d) observación etnográfica. Los resultados del trabajo muestran que la inmigración y condiciones de vida en las áreas de residencia contribuyen a que los nuevos inmigrantes se sientan desconectados de las "comunidades" que les rodean. Esta desconexión puede tener efectos negativos en su salud física y mental.

Palabras clave: migración, población inmigrante, hispanos, vulnerabilidad, VIH/sida, Nueva York.

 

Introduction

New York City (NYC) and its surrounding areas accounted for 91 per cent of New York State's total increase in foreign-born populations from Central America between 1990 and March of 2000 (U.S. Census, 2000a). In 2000, approximately 136,000 Central Americans resided in NYC and the surrounding counties (U.S. Census, 2000b, U.S. Census, 2000a). Of these, 98,000 (72 per cent) were born in El Salvador, Guatemala or Honduras (U.S. Census, 2000b). In addition, more than 600,000 individuals classified as Hispanic in the New York Metropolitan Area report their native countries as Mexico or the Dominican Republic (U.S. Census, 2000b). Demographers argue that U.S. Census figures underestimate the size of these populations due to the undercount of undocumented residents (Cordova, 1999).

Together with their demographic growth, the recent attention garnered by the rising number of HIV diagnoses among Hispanic groups in the United States (Hall, 2003, Centers for Disease Control and Prevention, 2000, Hispanic Federation, 2003) challenge researchers, advocates andpolicymakers to identify prevention and care priorities that address the contexts and needs of these populations. However, researchers, advocates andpolicymakers might benefit from conceptualizing concentrations of new immigrants in ways that reflect their composition, social dynamics, economic andhealth status and permanency. Thus, New Hispanic Communities and HIVRisk¹ was designed as a short-term, qualitative, exploratory study of new immigrant groups in urban, suburban and semi-rural locations from the Dominican Republic, Guatemala, El Salvador, Honduras and Mexico. The overall objective was to make policy and planning recommendations to address the risks for HIV/AIDS experienced by these groups in the New York Metropolitan Area. The data are thus used to describe and compare the sociodemographic characteristics of these immigrant groups as well as the cultural and environmental factors that provide the context for risk and prevention of HlVAIDS and other health challenges. This approach involved, as well, the identification of risk and protective factors embedded to varying degrees in immigrants' multiple cultures and sub-cultures. Inherent in this approach was the theoretical assumption that shared ethnic, experiential and historical elements influence and shape patterns of behavior and responses to new environmental options, alternatives, obstacles and risks (Handwerker, 2002). These complex social and cultural processes were seen to influence health vulnerability for immigrants in many ways (Carrier and Magaña, 1991, Díaz, 1998, Marin, 1994).

The conundrum of "Community"

The problem of multiple definitions of "community" emerged as the study began to define and locate the target groups. Confusing and even contradictory meanings of "community," as interpreted by social and political scientists with their own disciplinary definitions and assumptions, has been an issue for decades (Hillery Jr., 1955, Hillery Jr., 1959). Discussions surrounding the "tremendous ambiguity" of this term (Phelan, 1996) point to a challenge for the parallel worlds of research and policy: different meanings which are assumed to be self-evident (Jewkes and Murcott, 1998). An especially important perspective emphasizes the role that communities play as "secondary" groups between "state" and "individual" (Durkheim, 1964) and as mediators between micro andmacro levels of the political and social processes affecting health and development. The globalization of current public health challenges and of the HIV/AIDS pandemic make it increasingly necessary to understand the role of "community" as it impacts upon the individuals and families who shape its social and structural evolution (Barnett and Whiteside, 2002, Kawachi, 2003). It is equally important to identify the processes by which communities become intelligible to themselves, and to reach some consensus regarding the definition of community for science-based planning and for policy formation (MacQueen et al, 2001).

Public health professionals have long appreciated the complexities of "community" (Drevdahl, 2002), especially in the implementation of community-basedinitiatives. However, their efforts have often been thwarted by expectations of cohesion, shared goals, abilities and desires for collective action that do not exist. As Barnett (2002) observes:

The reality is that arange of interrelated factors determines how individuals interact and if they collectively constitute a community, which include their history, cultural framework, the extent to which people as individuals and in kin groups know and routinely interact with one another, and levels of civil and social organization.

Categorization affecting health disparities

The lack of consensus and the impact of inappropriate definitions of "community" become especially salient when such terms become barriers to effective policy, action and advocacy in the face of serious challenges to the health of large, disparate and geographically diverse populations. Themuch-used term "Latino," for example, does not fit any functional definition of "community." In fact, the debated emergence of this term in opposition to "Hispanic" is associated with the struggles of various populations of Latin American immigrants, Chícanos and Puerto Ricans and their descendants to establish pan-ethnic ties in the U.S. (Padilla, 1985,Oboler, 1995). The umbrella category "Hispanic" also obfuscates the characteristics and needs of large national and ethnic populations in the U.S. Immigrants from Latin America and the Caribbean, for example, are lumped together within this category, masking differences in migration experiences, health status, educational levels, language, and other areas. Thus, in policy and academic circles, and amongmembers of the populations "Latino" and "Hispanic" supposedly describe, the utility of these labels is subject to intense debate. Even when comprehensive categories are employed to direct resources, their use can privilege the more visible segments of the populations included and risk the omission of those for whom visibility might itself be a risk.

Research methods: a qualitative approach

The research utilized a qualitative approach to identify the range of experiences, attitudes andbeliefs relating to HIV riskby men and women of the target groups. These methods were also used to develop rapport, to facilitate access to settings and hard-to-reach groups and to obtain information on the social context of behavior and its influence on HIV risk. Qualitative data collection involved: a) semi-structured, in-depth individual interviews; b) focus groups; c) key informant interviews and a focus group with advocates and providers in health and social services; and d) ethnographic observation in the communities. Interview instruments were designed to explore: individual and collective living conditions; continuities and changes in attitudes, behaviors, and interactions with existing social networks and environments; attitudes and behaviors related to HIV and other STIs; and access to health and other social services.

Research sites and recruitment

Data were collected in New York State between 2002- 2003 in two field sites: a) the contiguous counties of Westchester and Putnam, composed of urban, suburban and semi-rural areas; and b) the semi-rural North Fork of Suffolk County, Long Island. These sites were selected to represent differences in new immigrants by urban, suburban, and semi-rural residence. Participants were recruited at each site using a snowball approach initiated by community leaders and providers. Because of fear of immigration authorities, the research team began field activities by establishing contacts at each site with the assistance of trusted community advocates and leaders. Preliminary fieldworkhelped identify individuals and the specific towns and villages where researchers developed collaborative relationships. Since education and literacy levels were uniformly low, verbal presentations of informed consent information were made before each interview. Interviewers were provided with contact information for local health and social service agencies in each location.

Sample

Men and women (n = 51) from the five countries participated in individual interviews. Criteria for participation included: age 18 or older; born in the Dominican Republic, El Salvador, Guatemala, Honduras, or Mexico; and having lived in the U. S. for less than three years before participation in the study. One focus group and 26 individual interviews were conducted with key informants including social workers, nurses, county officials, immigrant advocates, outreach workers, business owners, religious leaders, and HIV/ AIDS educators. Elevenfocus groups were conducted with individuals recruited from the same countries using the same criteria (n = 86), and organized by nationality, sex, and site.

Data analysis

Data included ethnographic field notes, notes and transcripts of all interviews and focus groups. Other sources of information included print media coverage of local issues regarding immigration and census data. Focus groups and individual interviews were taped and transcribed in Spanish. Multiple analysts coded textual data in Spanish. Research questions were explored using multiple methods and multiple data sources on key issues. Atlas.ti and FolioViews, both qualitative, text-based software programs, facilitated the identification of patterns and themes relevant to the study objectives within and across groups.

 

Results

Sociodemographics

The convenience sample of the study involved a majority of young men who migrated by themselves seeking to work and to send money to sustain their families. Some women also immigrated by themselves to join family members. However, most women interviewed had come with their partners and/or children, or had joined partners after the latter established themselves. Overall, the mean age of respondents was 31 and more than half of all participants (63 per cent) were 30 years of age or younger. The mean length of residence in the United States was of less than two years. The majority of participants were either married (42 per cent) or partnered (15 per cent). Approximately 36 per cent of all participants were single. Women respondents were generally more likely to be married or partnered than men were (about 75 per cent of all women respondents were married or partnered vs. approximately 45 per cent of all men).

Levels of literacy were on average between 5^th and 6^th grade.Most respondents had only partial elementary schooling. Mexican immigrants were present in all locations. Central American participants were more visible within the smaller towns and semi-rural locations. Of the Central American participants, Guatemalans appeared most numerous and visible throughout the two sites while the number of Hondurans appeared limited. Dominicans were most visible in the urban and suburban locations in Westchester County. Data suggested that many of these new immigrants were undocumented. Most respondents referred to communicating in English as one key obstacle in their lives. Typical jobs included but were not limited to construction, landscaping, farming, retail and sales, painting, cleaning, baby-sitting, restaurants, etc. Some men with longer experience in the U.S. had traveled between sending and receiving areas a few times, but approximately 77 per cent of the men and women interviewed were in the U.S. for the first time.

Emergent communities

The traditional goals of immigrants continue to influence migration: to help the family; to send money home; "to help myself;" to obtain better education for children; to obtain better medical care; and so forth. Women also explained that they migratedbecause men stayed "a long time" in the U.S. and they feared that distance mightthreaten the stability of their relationships. Some women brought children because they had no one with whom they could leave them.

Historically, networks in receiving countries structure migratory flows by facilitating migration and assuring initial survival. Yet, a number of respondents discussed how information on the type of environment also influenced their decision. Some settled in the North Fork, for example, because of its reputation as a quiet, rural place, with what a respondent called "ambiente de campo." Regardless of how attractive a suburban or semi-rural location was to respondents, access to the support of relatives and/or friends was a key factor in migration decisions. Most respondents reported that they chose to settle in areas where some pre-existing social and/or kin networks from their home villages were reforming in fragmented forms. One Central American woman explained how social networks provide support for migration, funding, and resources to new arrivals:

[A] ese conocido...amigo o familiar...[uno] le avisa con tiempo que uno quiere viajar, entonces él le busca un cuarto si él tiene en su casa, sino lo busca con un amigo en otro lado y ya cuando...viene paga la renta de uno porque uno no trae dinero. Ya va a buscar un trabajo para uno y ahí va, empieza a trabajar uno y ahí va pagando uno lo que debe.

[That] person you know.. .friend or relative... [one] tells that person that you want to travel with anticipation and he then helps find a room for you if he has a house, and ifnothe asks a friend ofhis in anotherplace and then.. .pays the rent because one does not bring money. Then helps you find a job and so it goes, you start working andyou start paying what you owe.

In some cases, whole kin networks from small villages were reported to have migrated to smaller towns in Westchester, Putnam and Suffolk counties. Immigrants described how these networks supported the maintenance of traditional norms and behaviors despite new and sometimes conflicting U.S. influences and pressures. At the same time, they described new attitudes and behaviors, as well as new forms of allegiance and interaction across lines of nationality and ethnicity. This appeared more frequently where pre-existing home networks were sparse, and where new immigrants found themselves having to access goods and services out side kin, ethnic and/or national networks. Yet with or without receiving networks, most new immigrants did no trecognize themselves as part of any "community".

Living and working conditions

Interviews revealed that most immigrants in the study shared crowded housing upon arrival, even when whole families arrived together or were reunited. Participants reported that living quarters tended to be expensive and in deplorable conditions.Menlivinginall-malehouseholdsespeciallyworriedthatneighbors would notice the overcrowded conditions and report houses and apartments hosting immigrants to local authorities. Most respondents mentioned the loss of privacy and the hardships of sharing in crowded housing. However, the adjustment appeared easier for those who migrated within family networks if the family rented the room, apartment or house where new immigrants lived. Access to these housing options appeared easier for Dominicans who appeared able to count on already integrated family and social networks. In some cases, however, Dominicans also reported difficulties dealing with new living arrangements. As one Dominican father explained, "uno tiene que tener la mente bien.. .fuerte para poder soportarlo. A veces a uno le.. .entran deseos de arrancar, de irse de aquí/One has to have a mind that is very.. .strong to put up with it. Sometimes one just wants to get up and leave."

The many obligations new immigrants faced —to their families, to pay debts incurred in migration and to sustain themselves in the new environment— made work the focus of their lives. Because access to work opportunities was limited and inconsistent, many participants reported living through periods with long and/or irregular working hours and then facing extended periods without work. Work available for new immigrants was generally temporary and/or seasonal. This instability of the labor market also caused respondents to feel unstable in their lives in the U.S. It was typical for participants to express frustration at the scarcity of work, especially during the winter. A number of men and women reported that their situations were so dire that they requested the return of remittances from home. A number of the women reported being housewives, but most female respondents worked in laundromats, restaurants, cleaning and gardening. Some of the men had temporary or permanent jobs doing manual labor. Among the five groups, opportunities for relatively steady employment (e.g. work in bodegas and restaurants) and some upward mobility appeared more among Dominicans in urban and suburban locations in Westchester County. Day labor appeared more common for Central American and Mexican immigrants.

Obstacles to "Community"

Recent exposure to arduous conditions for travel and to challenging living conditions appear to influence a sense of emotional and psychological dislocation, reported by numerous respondents. This dislocation may hinder new immigrants from seeing themselves as part of an emerging "community." As one Central American man put it,

Es que aquí no estamos organizados por comunidades, uno dice "comunidad hispana" pero cada quien jala por su lado, pero no hay comunidad organizada. Organización se ve a veces en las iglesias, que ahí está organizado unos que dicen "vamos a hacer tal cosa para la comunidad." ¿Pero comunidades organizadas? No hay.

Here, we are not organized by communities. One says 'Hispanic community,' but everyone fends for themselves, but there is no organized community. Sometimes, you can see organization in the churches, that someone is organizing people and they say "let's do this thing for the community." But organized communities? There are none.

"Fending for oneself," a common theme, points to various factors that made difficult for new immigrants to recognize themselves as part of a collectivity. Because new immigrants reported devoting most of their time to their jobs or to finding work if unemployed, the workplace was frequently cited as one of the few sites of social interaction with individuals from other regions of their countries, or from other countries. However, differences in positions occupied within the labor market, together with the concentration of immigrants from specific countries in particular areas, appeared to influence the formation and type of workplace relationships. In addition, the irregularity of work schedules and the competitive contexts in which work is often obtained was said to cause competition and divisiveness, pitting immigrant groups and individuals against each other. In some situations, differences of nationality were used to lay claim to particular sites for day labor. In one of the larger cities in Westchester County, for instance, there were two sites for day labor —one where Mexicans predominated and another Ecuadorian men predominated. When asked if there was mixing between these two groups at each site, day laborers described antagonisms between these two larger groups that necessitated having separate recruitment sites.

Access to more established and developed networks may explain why work was less of a dominant force in Dominican relationships and sense of community than for Mexicans and Central Americans. Even Dominicans new to suburban and urban areas of Westchester County had some well established networks which gave them relative employment stability and the possibility of upward mobility in the U.S. By contrast, existing social networks available to Mexicans and Central Americans were not nearly as developed or influential in the areas where they settled.

In addition to competition for jobs, the undocumented status of many new immigrants made them hesitant to interact with others outside of their networks unless on the job. Lack of documentation also limited immigrant men and womento informal work sector and to unfavorable working conditions (10-hour work days were typical, as were reports of abuse from employers). The lack of documentation was also a significant obstacle to many crucial needs such as driver's licenses, insurance and the use of banks.

The combination of an undo cumented status with relativel y limited exchanges with people of other nationalities appeared to encourage some respondents to think of their life in the U.S. as transitory, a stage of "sufrimiento/suffering" they have to endure for the sake of those left in the homeland. As one participant put it, "En Estados Unidos, para ganarse 10 dólares tienen que sufrir primero / In the United States, to make 10 dollars they have to suffer first."

Another obstacle to community cohesion and the formation of new social relations fostering a sense of community were the limited spaces for socialization. Among the populations studied, differential access to social outlets was identified according to geographical locations and pre-existing networks and infrastructures. In Westchester/Putnam and in the North Fork, men appeared to have a few opportunities to socialize in local or nearby bars. They were also meeting men from other ethnic/national groups at informal sports activities where numerous Latin American groups gathered. Women with children in school had more social contact with other women than those without children. Young women who arrived in the target areas with or to join partners, who did not have work and who did not have friends or relatives in the area, stayed alone unless they shopped or did laundry with their partners.

Finally, percrived/lived instances of discrimination discouraged participants from feeling a sense of attachment to their receiving areas. As a Dominican respondent put it,

En Tarrytown, hay muchos negocios que son de blancos. Una vez yo... quise beber un par mas de cervezas y...Yo fui y entré y a mí no me quisieron vender... Dijeron, "no, está cerrado." Y me devolví y me salí.

¿Cómo tú sabías que el negocio todavía estaba abierto?

Sí, porque había gente, muchos y eran blanquitos y no era tan tarde.

In Tarrytown, there a lot of business for whites. One time I... wanted to drink another couple of beers and.. .1 went and I went and walked in and they did not want to serve me... They said, "no, it's closed." And I turned around and left.

How did you know that the business was still open?

Yes, because there were people there, many and they were white and it was not so late.

Reactions of local authorities and residents to the significant growth of the Hispanic populations during the 1990-2000 period in the study areas ranged widely. Incidents of violence, discrimination, and general discomfort towards immigrant presence throughout the counties of Westchester, Putnam and Suffolk suggested that different populations and leaders were working to identify and address the needs of new immigrants, albeit slowly (Gross, 2000, Gootman, 2001, Jones, 2001, Worth, 2001). Despite these welcome advances, the relegation of new immigrants to the most marginal sectors of the labor market, their living conditions, their suspicions of each other and not feeling welcome may contribute towards a lack of investment in any "new" community and the goal of retiming home despite the economic realities.

Mental and physical health

Immigrants' long-standing health concerns emerged frequently during interviews and focus groups. Health and social service providers in these areas reported serious pre-existing health conditions among these groups, including: malnutrition, anemia, diabetes, asthma, toxoplasmosis, STIs (syphilis and gonorrhea), parasitic infections, hypertension, cardiovascular problems/high cholesterol (especially among Dominicans), malaria, tuberculosis, and dental decay (Shedlin and Shulman, 2004). The lack of communication skills and the urgency of generating income, however, resulted in their lack of attention to health unless the ability to work or care for families were threatened.

Most interviews revealed the salience of mental health issues as well. Interviews illustrated the impact of geographical and cultural disruption compounded by the loss of social and emotional support, as well as economic pressures. It appeared that these conditions and priorities influenced feelings of disconnection and isolation, especially for men who migrated alone.

Difficult living conditions, the reliance on limited, kin-based social networks and a sense of disconnection from the larger "community" where they resided, may also contribute to the "stress" and "depression" cited by many of the study participants. Men and women reported lasting mental health effects related to the journey and the "suffering" they endured immigrating to the U.S., as well as from leaving their homes and families and going into debt. Central American men, for example, used the word "desperation," and expressed feelings of social isolation and frustration at not knowing the U.S. and local laws or acceptable norms. Mexican women discussed stress and depression due to economic issues and homesickness, and both men and women from all countries described discrimination (largely from other, more established immigrant groups) and their disillusionment with prior expectations for their new lives.

Drug abuse and sexual behavior

To date, little research attention has been devoted to the HIV risk behaviors of persons newly arrived in the U.S., especially those who use drugs. Westermeyer (1999) asserts that: a) immigrants are at risk of abusing the substance or substances that were abused in their countries of origin, and b) young immigrants are apt to begin using substances that are abused in the new country of relocation. Even for those individuals not using drugs when they arrive, however, the eastern migratory stream is known to have environments of widespread drug use and HIV infection (Inciardi, 1999). Among the study populations, alcohol and substance abuse were closely related to the venues and contexts of social interaction available to them. Apart from the workplace and from some bars, members of these populations socialized in their living quarters. This was especially true for men sharing houses or apartments with other immigrant men. In these contexts, alcohol emerged as the drug of choice.

Respondents and key informants reported that "six-pack" was one of the first words in English that immigrant men learned. Men and women reported that drinking took place in their own or friends' houses because there were few places to go and because men were afraid of the police. Women reported that men drank heavily and that they were frequently jailed locally for having fallen down drunk on the street or for drunk driving. It appeared that alcohol served as an outlet for men alone, depressed, and dealing with the stresses of a new environment without families and social support. Individual interviews with women have identified the initiation of alcohol use. Although occasional drinking among women in their home countries was noted —especially among women from the larger cities— it was suggested that women "consume(n) más (alcohol) de lo normal/consume more (alcohol) than normal" after migration. "Entonces aquí no da pena salir ya bien tomadas / Here, they are not ashamed of going out already drunk."

Social networks and spaces for socialization were also connected to the initiation of drug use. The research team observed construction workers in Westchester accepting and smoking marihuana from a supervisor. Despite the fact that study participants reported knowing of "boys" who offered to sell drugs, mostly morenos (blacks), respondents also knew of other Hispanics offering drugs to men in the fields. Most respondents said they came from rural areas where drug use, other than marijuana, was rare. The perspective of a Salvadoran male respondent, however, suggests that decisions of whether or not to accept drugs may be more related to their cost in relation to other daily necessities and not only because of social stigma attached to drug use. As he explained,

Cuando yo llegaba donde estaba un pollo chino ahi a comprar comida, ya a las once de la noche, decían [los vendedores], ya se acercaban y me decían si quería y me decían, "Twenty-five." Yo decía, "¿Veinticinco dólares por esto? No." Decía, "son cinco almuerzos que me voy a comer".

When I arrived at that place to buy food, at eleven in the evening, they (drug dealers) would say, they would come close to me and they would ask me if I wanted and they said, "Twenty-five." I would say, "Twenty-five dollars for this? No." I would say. "I will eat five lunches for that amount."

It appears that the involvement in using and selling is being initiated in the U.S. Participants have also suggested generational differences in immigrants' attitudes towards drugs. According to some respondents, younger men were more likely to begin marijuana and cocaine use while older men continued patterns of alcohol use, such as binge drinking of (mainly) beer.

In addition to the possibilities for HIV risk raised by the abuse of alcohol and other drugs, a number of other factors were identified which may influence sexual risk for HIV/AIDS and other sexually transmitted infections (STIs). Men who migrated alone appeared to be at risk because of excessive drinking and use of sex workers. Their social isolation, stresses of daily life, scarcity of potential sexual partners and a lack of awareness of prevention and the need for protection appeared to put these men at additional risk. Other contextual factors are at work as well, such as differential access to spaces for socialization and meeting potential sex partners. Among migrant farm workers, for example, employers may contribute to their workers' risk by permitting the import sex workers on payday for the "use" of dormitory domiciled workers. Alcohol use in these situations, together with a reliance on the sex worker to be the condom provider, appeared to increase the risk of unprotected sexual encounters. A provider in Westchester reported that in many situations, interested men called the beeper of an individual who would transport women from Manhattan to service a group of men in an apartment or set up a sex worker in a van to provide sex to a group of men. Given the conditions in which these encounters are said to take place, and the number of partners involved, both sex workers and their clients appear to face significant risk for HIV and other STIs. While men reported having protected sex with sex workers and always using condoms, the majority mentioned knowing other men who did not. Those that stated that sex workers always used condoms for their own protection also seemed to know of sex workers who would not use them if the man chose not to. Regardless of these contradictions, most immigrant men perceived little o rno risk in having sex with women deemed "clean" or "safe"—be they the 'Vives" or "girlfriends" back in their countries of origin, in the U.S., or the women they dated for several weeks or months.

The subject of men having sex with other men was difficult to broach with participants, though women were generally more aware and willing to talk about the behavior than men. While a few of the men interviewed commented on the issue, they tended to deny all knowledge of this practice within their networks. Key informants, however, reported hearing about these behaviors within some of the all-male households. In addition, local providers stated that in rural and suburban communities, "many gay men do not 'go public'" because they are small communities where "everyone knows everybody else's business." "Most of the gay men prefer to use New York City as their social and medical focus. It's an easy hour to New York City." But, suggested the providers, "this is usually difficult for poor, Latino immigrants who do not have the economic or social options that white middle or upper class MSMs" (Shedlin and Shulman, 2004).

 

Discussion

If public health policies and programs are to be effective, they must reach some consensus in defining these evolving immigrant "communities" as well as in identifying the health risks of the groups that comprise them. Even a "working definition" of "immigrant community," however, must go beyond the identification of nationalities, ethnicities and geographic boundaries. Any definition which effectively facilitates planning and resource allocation must incorporate a consideration of the stage(s) of acculturation influencing populations and institutions as well as the degree of integration into the larger sociopolitical (and epidemiological) environment.

It would be inappropriate to make generalizations about the participant groups studied because of the small and non-representative sample of men and women from five different countries recruited in two New York field sites. The sample does permit an idea of the range of sociodemographic characteristics, challenges and resources as they relate to migration, community formation and health for new immigrant groups in New York. The documentation of fragmented networks; the importance of existing kin and social networks; the economic, legal and cultural factors affecting an initial stage of acculturation; and the lack of institutional resources all serve to help to define these communities.

However, the identification of these elements and processes, which serve to define new immigrant communities, also clarifies the urgent need for interventions tailored to the specific realities of their risk for HIV/AIDS. These communities at risk should be considered a high priority for prevention and education efforts. The themes and patterns identified in this study support the recommendation that key elements to achieving effective prevention interventions will be those which build on cultural norms, network, human and institutional resources, and support infrastructure and community-building.

 

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Nota

¹ This research was made possible by a grant from the National Institute of Child Health and Human Development, National Institutes of Health and Human Services (Grant Number HD042970). We wish to thank the agencies and individuals who generously gave of their time and knowledge to inform this study. Inparticular, we thank members of the immigrant communities for their willingness to share their ideas and experiences. Two dedicated advisory groups were The Lower/Mid-Hudson Latino HIV Network and the Spanish Apostolate of Riverhead. We express our gratitude to Sister Margaret Smyth, Yeny C. Mclntyre and Victor Alvarez. Additionally, we thank Marianela Merejo, Julio Diaz and Juana Huertas for their contributions as consultants, and Nestor Ivan Rocha for his resourcefulness and guidance. We are grateful to our NDRI colleagues Sherry Deren, Milton Mino and Dorline Yee as well as to the anonymous JNMA reviewers for their comments on earlier versions of this article. Finally, our thanks to Angela Martinez and Carol Tobkes for their interviewing and insights.

 

Información sobre los autores

Carlos Ulises Decena. Profesor auxiliar en los Departamentos de Estudios de Género y de la Mujer y en el de Estudios Hispanos del Caribe y Puerto Rico, en Rutgers, en la Universidad Estatal de Nueva Jersey en Nuevo Bruswick. Anteriormente fue director de proyecto en el Instituto de Investigación del sida y de los Institutos de Investigación y Desarrollo Nacional, ONG. El Dr. Decena es un científico social interdisciplinario, quien obtuvo el grado de doctor en el programa de estudios americanos en la Universidad de Nueva York. Su libro, Tacit Subjects: Dominican Transnational Identities and Male Homosexuality in New York City está bajo revision por la editorial de la Universidad de Duke. Correo electrónico: decena@ndri.org

Michele G. Shedlin. Profesora de Ciencias de la Salud II del Departamento de Sociología y Antropología y miembro honorario del Centro de Investigación en desigualdades de la Salud Hispánica de la Universidad de Texas en el Paso. Anteriormente fue investigadora y subdirectora de Investigación en Salud Internacional y del Inmigrante en los Institutos de Investigación y Desarrollo Nacional de Nueva York. La Dra. Shedlin es médica antropóloga con una basta experiencia en investigación sobre salud reproductiva, abuso de substancias y sida en América Latina y Estados Unidos. Ha diseñado e implementado estudios de comportamiento e investigación en capacitación a la comunidad, a nivel regional y nacional, para informar y evaluar programas de prevención y cuidado. Actualmente está involucrada en la investigación de los riesgos del VIH para población homosexual en Nueva York a través de fondos del NIH (Institutos Nacionales de Salud), así como en investigaciones sobre aculturación y riesgo de nuevos migrantes hispanos y redes de drogas y sida en Nicaragua. Correo electrónico: sheldin@ndri.org