Affordable Health Services in NYC's Immigrant Communities.

The Arab-American Family Support Center (AAFSC) is a non-profit, non-sectarian organization established in 1994 to provide culturally and linguistically competent, trauma-informed social services to low-income immigrants and refugees in New York City (NYC). While we support anyone who walks through our doors, over 27 years, we have gained expertise serving Arab, Middle Eastern, North African, Muslim, and South Asian (AMENAMSA) communities. We are dedicated to helping these populations overcome a nexus of challenges, including lingering trauma, discrimination, poverty, and acculturative stressors. Our staff speak 36 different languages – including Arabic, Bengali, Urdu, Farsi, Spanish, Nepali, and Wakhi – enabling us to support populations that mainstream providers struggle to reach. As a settlement house, we are geographically embedded in the communities we serve, with 13 locations across all five boroughs of NYC.

As a social service organization providing vital resources to underserved and undercounted communities, AAFSC crafts our strategic approach in a manner that responds to the unique needs of the communities we serve, and with an understanding of the nuanced challenges that impact community well-being. Recognizing that holistic health is at the center of individual, family, and community well-being, AAFSC has always prioritized programming that targets the advancement of mental and physical health and promotes awareness of and access to the health services needed to remain well. Our Community Health & Well-Being program provides service navigation and enrollment assistance for health insurance and coverage and the Supplemental Nutrition Assistance Program (SNAP), as well as free and linguistically accessible mental health counseling. Additionally, our team leads outreach initiatives that promote awareness of and access to essential health services including preventive care, specialized services, and protection against COVID-19 infection. Through our extensive history working to promote health and well-being in low-income immigrant communities, we have become well-acquainted with the gaps in linkages connecting families to the health services they need.

As part of our Community Health Needs Assessment, the AAFSC Research Institute is releasing the following Story Map, which examines the accessibility of affordable health services in low-income, underserved, and socially vulnerable communities in NYC, including those with a high concentration of Arab, Middle Eastern, North African, and South Asian community members. AAFSC recognizes that these populations are not distinctly identified in traditional surveys – including the Census. We hope this Story Map will serve to further educate stakeholders and advocates about the geographic relationship between vulnerable immigrant communities and affordable health services. In this way, we aim to ensure health services are accessible to the immigrant and refugee families who need them.

In this report, we examine the distribution of Federally Qualified Health Centers (FQHCs) and their proximity to underserved Arab, Middle Eastern, North African, and South Asian immigrant and refugee communities. An FQHC is a community health center funded by the Health Resources and Service Administration (HRSA) and created to care for underserved communities, who are experiencing barriers to accessing health services.  FQHCs typically target community members who are low income and/or uninsured, those with limited English proficiency, individuals and families experiencing homelessness, and those living in public housing . These health centers are crucial to lower-income communities as they provide life-saving health care services such as family and internal medicine, women’s health, pediatrics, and enrollment in  WIC  (Women, Infant, and Children - the program aimed at providing nutritious food to low-income pregnant women, postpartum women, infants and children up to 5 years old), among many others. According to New York City Department of Health and Mental Hygiene, these centers “provide comprehensive primary care services to medically underserved areas or populations” and they “predominantly serve patients who have Medicaid (or other need based public insurance) or who are uninsured.”  For those with no insurance coverage, FQHCs charge fees on an income-based sliding scale .

Vulnerable communities need health providers that accept public insurance. Based on data collected by the American Community Survey (ACS), 43% of NYC residents utilize public health insurance and 8% of residents have no insurance at all. This data likely underrepresents the experience of undocumented immigrants who tend to decline participation in such surveys and are most likely to not have any form of insurance. According to the  National Association of Community Health Centers , 91% of FQHC patients are living in or near poverty per the U.S. Federal Poverty Guidelines, 82% are uninsured or publicly insured, and 63% are members of racial and ethnic minorities. Among the most vulnerable individuals in the uninsured population, ‘newly arriving immigrants’ face several challenges that threaten their physical and mental health, including trauma experienced from their migration journey, gaps in income upon arrival, and ineligibility for essential federal benefits that promote health and well-being. These individuals are especially in need of quality health services to support their adjustment to New York City and stand to benefit significantly from physical proximity to FQHCs.

As illustrated in the map above, New York City is home to a significant number of FQHCs. Still, a stark disparity exists in distribution of FQHCs across NYC neighborhoods, particularly in the areas of South Brooklyn, Eastern Queens, Mid-Queens, and Southern Staten Island. For residents in these neighborhoods, a lack of nearby FQHCs can deter access to essential health services, particularly in areas where limited efficient transportation methods create onerous travel barriers. According to the Human Resources and Services Administration, travel time of 30 minutes is ‘a threshold for reasonable travel to primary care’. For many residing in these neighborhoods, commutes to FQHCs using public transportation exceed this threshold.

Researchers have examined the geographic relationship between FQHCs and communities before. A study by Chang, Bynum, and Lurie found that the expansion of FQHCs between 2007 and 2014 did not necessarily ensure that new FQHC sites were reaching the previously excluded, disadvantaged populations who have preexisting challenges accessing care. Per their study  ‘Geographic Expansion of Federally Qualified Health Centers 2007-2014 ’, the scaling pattern indicated that new sites were added in the proximity of already existing FQHCs as opposed to areas without access to medical care. The agency approved funding for certified FQHCs that ‘tended to locate in relatively less impoverished areas.’ This concerning trend illustrates the need for continuous examination of public health planning initiatives and their effectiveness in geographically targeting communities where health disparities are most urgent.

AAFSC has developed expertise serving Arab, Middle Eastern, North African, Muslim, and South Asian communities, who experience a unique nexus of challenges – including lingering trauma, discrimination, poverty, and acculturative stressors – yet face barriers to accessing the necessary support to thrive. Despite the unique lived experience of these populations, there is a significant dearth of data that appropriately disaggregates individuals who hold these identities. In many cases, those identifying as Arab, Middle Eastern, or North African are identified as “White” in mainstream data collection, such as the Census. Similarly, the diverse array of populations categorized under the “Asian” racial/ethnic identity, are painted with too broad a brush, leaving the unique experiences of South Asian community members de-identified. AAFSC is committed to advocating for more equitable data disaggregation practices which allow our communities to see themselves reflected in data. Unfortunately, very little US Census data exists to map these communities with strong confidence. While we continue our ongoing data disaggregation advocacy efforts, for the purposes of this Story Map, we are utilizing what data is available to identify the population of immigrant communities from countries of origin in North/East Africa, Western Asia, and South-Central Asia.

The below map with an interactive slider shows a visual comparison of the distribution of NYC population who either through the language they speak, or through their country of birth may fall within Arab, Middle Eastern, North African, and South Asian population. The census tracts in darker shades of purple indicate higher density of these populations.

A comparative view of Map 2 and Map 3 offer an interesting insight – the spread of the population speaking either Arabic or some other Indo-European languages is wider and greater than that of the population of those with a country of origin in Arab, Middle Eastern, North African, and South Asian countries. This spatial analysis indicates that even those census tracts negligibly resided by these populations house a remarkable number of people speaking in one of the languages ethnic to these populations. The data on languages reflected on Map 3 also includes the younger population born in the US including second and third generations in addition to the recently arriving immigrants, refugees, and the first-generation immigrants.

AAFSC has vast experience working with immigrants as well as children of immigrants and has come to recognize that it is not only the first-generation immigrants but even those who are born in the US and hold these identities that remain underserved. Immigrants and children of immigrants often require linguistically accessible support, interventions, and health care.

As insufficient disaggregated racial/ethnic identity data exists to quantify the distribution of Arab, Middle Eastern, North African, and South Asian  communities in New York City, AAFSC leveraged two demographic data points captured in the American Community Survey (2019): ‘languages spoken at home for the population 5 years and over’ and ‘country of origin for foreign-born population’ to create an original dataset approximating the size and distribution of these communities in NYC. We used Census estimates in both categories to represent an approximate number of NYC residents who (either through the language they speak or their country of origin) may fall within the Arab, Middle Eastern, North African, and South Asian immigrant population. We understand that this method might underestimate the number of individuals within these communities, and we see this as a starting point from which future special analysis and data disaggregation can be based. 

To create Map 2, we included the Census estimate of foreign-born population from North/East Africa (Sudan, Morocco, Egypt, Somalia, Ethiopia, Eritrea, and Other), West Asia (Yemen, Turkey, Syria, Saudi Arabia, Lebanon, Kuwait, Jordan, Israel, Iraq, Armenia, and Other), and South-Central Asia (Uzbekistan, Sri Lanka, Pakistan, Nepal, Kazakhstan, Iran, India, Bangladesh, Afghanistan, and Other).

To create Map 3, we isolated two language categories that Arab, Middle Eastern, North African, and South Asian languages fall within: Arabic and Other Indo-European languages. The latter is a broad category and includes Persian, Farsi, Dari, Gujarati, Urdu, Punjabi, Bengali, Nepali, and Hindi along with other Indio-European languages. Since ‘Other Indo-European languages’ also includes French, Haitian, Italian, Portuguese, German, Dutch, Yiddish, Greek, Russian, Polish, Serbo-Croatian, and Ukrainian languages, we understand the limitations of this method, and must work within these constraints. Additionally, Amharic, Somali, and other ‘Afro-Asiatic languages’ are not appropriately disaggregated in US Census data generated from the American Community Survey, rendering Black and African Muslim communities who speak languages other than Arabic or other Indo-European languages, unrepresented in publicly available data.

While this information offers a look at the presence and distribution of Arab, Middle Eastern, North African, and South Asian immigrant communities, gaps remain in the quality and completeness of this data. We know from our extensive work promoting completion of the U.S. Census in undercounted communities that immigrant households are often reluctant to participate in data collection efforts due to concerns regarding confidentiality, mistrust of government agencies, and fears of deportation. For those who do participate in these surveys, reluctance to identify as an immigrant, due to intimidating political rhetoric, discrimination, and xenophobia, may cause additional inaccuracies in the data that is collected. Additionally, data packages produced by the US Census do not always classify and/or disaggregate languages and countries of origin in a manner that allows for analysis of all subgroups within the target population. In examining the data depicted in these maps, we are conscious of its limitations and operate with an understanding that the figures reflected are likely undercounting the true Arab, Middle Eastern, North African, and South Asian immigrant population in NYC.

To further contextualize the publicly available data being examined, Map 4 depicts the distribution of families served by the Arab-American Family Support Center in New York City. While limitations to available data exist (our dataset does not include individuals living in domestic violence shelters or those who decline to provide address information), the provided information illustrates the extensive presence of immigrant communities across all five boroughs.

Leveraging the American Community Survey data on Arab, Middle Eastern, North African, and South Asian immigrant communities for 2019 and NYC census tract total population for 2019, the average of these populations per census tract is 5 percent. Overall, 166 census tracts in NYC have at least 10% of their residents who migrated from these regions. Within 19 census tracts, Arab, Middle Eastern, North African, and South Asian individuals comprise at least 30% of the census tract’s total population.

We conducted a travel time calculation to examine the distance between the nearest FQHCs from the approximate center of census tracts resided by these populations. All neighborhoods with high concentration of this population group have at least one FQHC within 30 minutes driving distance by car. However, travel by public transportation (the method predominantly used by low-income immigrant community members in New York City) is often much greater, particularly in areas across Brooklyn, Queens, Bronx, and Staten Island where subway access is limited.

Social Vulnerability Index (SVI) provides an additional helpful framework for examining the compounding demographic and socio-economic factors that place certain populations at a higher need for accessible services. Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) is a measure “to help public health officials and emergency response planners” identify and map the communities that will most likely need comparatively more support before, during, and after a hazardous event like a man-made disaster, a natural calamity, or an outbreak of an epidemic.  The variables considered by SVI  are socio-economic status, household composition and disability, minority status and language, and housing type and transportation.

The residents of neighborhoods that are high in SVI are in imminent danger of falling victim to health crises due to their low-income status, unstable housing situations, minority status, and/or limited English proficiency.  SVI scores range from 0 to 1 where 1 indicates high vulnerability, and 0 indicates low vulnerability .

The areas in dark purple represent census tracts with high vulnerability. As reflected by the map above, a significantly large portion of the Bronx, Brooklyn, and Queens are highly vulnerable.

The following table lists the top 18 census tracts along with i) percentage of immigrant populations from Arab, Middle Eastern, North African, and South Asian descent, ii) social vulnerability index for the census tract, and iii) travel time from the approximate center of the census tract to the nearest federally qualified health center by public transportation.

 _{Sources for Table 1: Total Population by Census Tracts, American Community Survey, 2019; NYC Population by Country of Birth, American Community Survey, 2019; CDC/ATSDR SVI Index (Center for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry Social Vulnerability Index), 2019} 

Notably, as illustrated in the table above, twelve out of the 18 census tracts are currently in a highly vulnerable state, and three census tracts do not have a proximate FQHC within the 30-minute reasonable travel threshold when accounting for public transportation.

Reassuringly, the census tracts extremely high in social vulnerability index, in the neighborhoods of Jamaica Hills-Briarwood, Hollis, Mapleton-Midwood (West), Jackson Heights, Jamaica, Kensington, and Flushing-Willets Point are at an approximate distance of between 4 to 18 minutes by public transportation from their closest FQHCs.

The residents of Bellerose and Glen Oaks-Floral Park-New Hyde Park in Queens have a travel distance of about 34 minutes to 48 minutes to their nearest FQHCs, with SVI scores indicating a moderate level of social vulnerability.

It is clear, by examining the quantity and distribution of FQHCs across New York City, that these sites are in plentiful supply. There does appear to exist a visible disparity in the concentration of FQHCs in higher-income areas in Manhattan and lower-income neighborhoods (more likely to be populated by immigrants and refugees) throughout Brooklyn, Queens, the Bronx, and Staten Island. However, there are only a few localities within our target geographic areas where physical proximity to an FQHC exceeds the reasonable threshold for travel via public transportation. It is also evident that a relationship exists between the geographic positioning of Arab, Middle Eastern, North African and South Asian immigrant communities and the areas of New York City experiencing high social vulnerability. The high rates of social-vulnerability among nearly all census tracts populated heavily by Arab, Middle Eastern, North African, and South Asian communities – regardless of proximity to an FQHC – highlights potential gaps in healthcare access that are driven more prominently by issues of linguistic and cultural access. Over the course of our 27 years of work, AAFSC has become intimately acquainted with these access barriers, and we frequently encounter families who, despite living in a city heavily-supplied with healthcare resources, struggle to get the care they need.

Based on initial findings from AAFSC’s Community Health Needs Assessment, strong need (and preference) for in-language services, cultural ideologies and sensitivities around preventative care and screenings, and deficiencies in healthcare coverage and insurance, are prominent gaps that healthcare providers have yet to adequately overcome to ensure immigrant communities are receiving the full complement of essential health services in a quality and manner conducive to favorable long-term health outcomes.

As a community-based service provider with linguistic and cultural expertise, the Arab-American Family Support Center is actively leveraging these insights to inform our public outreach and health service navigation strategies to minimize the observed gaps in health access for vulnerable immigrant populations. We also call upon health service providers, policymakers, and stakeholders in the healthcare system to utilize these findings to enhance the availability of affordable health services physically embedded in Arab, Middle Eastern, North African, and South Asian communities. We stand ready to collaborate to ensure ALL New Yorkers have access to the care they need.