There are approximately 25 million foreign-born immigrants living in the United States, which is more than 13% of the nation’s total population. Of these individuals, it is estimated that about 11 million are undocumented; by far, the largest group of this immigrant undocumented population is Hispanic.
Although disparities in oncologic care in minority populations are well documented, far less is known about cancer care in the undocumented population. To shed light on the experience of undocumented patients with cancer, The ASCO Post spoke with two Latinx oncologists: Coral Olazagasti, MD, and Narjust Duma, MD, whose life experiences informed their determination to spread awareness of the challenges faced by undocumented patients with cancer.
Coral Olazagasti, MD
Narjust Duma, MD
Meet the Experts
Please tell the readers a bit about your background and current positions.
Dr. Olazagasti: I was born in Puerto Rico and always dreamed of becoming a doctor. After earning my medical degree in Puerto Rico, I came to the States for my residency at Mount Sinai Beth Israel. I’m currently an oncology fellow at North Shore-LIJ Health System, New Hyde Park, New York.
Dr. Duma: I was born in Venezuela. Both my parents were surgeons, and after they divorced, I spent a lot of time at the hospital where my mother worked. So, in a sense, that was my introduction into medicine. I received my medical degree in the Dominican Republic, my internal residency at Rutgers New Jersey Medical School, and my oncology fellowship at the Mayo Clinic, Rochester, Minnesota. I’m currently Assistant Professor of Medicine at the University of Wisconsin School of Medicine and Public Health, Madison.
Personal Stake in the Issue
What led to this line of inquiry about cancer care in the undocumented populations?
Dr. Olazagasti: My interest in marginalized communities began early, when I would go to my church community service group with my mom. During college in Puerto Rico, I joined a nonprofit organization doing work in Haiti, so that was when my interest in this issue really accelerated. During internship, my work with marginalized communities stalled a bit, as I didn’t have the right mentorship at the time. Then I met Dr. Duma, and we worked together on a paper about caring for undocumented patients with cancer. During our research, we found many things that debunked common misconceptions about these populations. One was the substantial contribution undocumented Hispanics make to the U.S. economy and social construct. For instance, about 50% to 75% of these marginalized immigrants pay state and federal taxes, which underscores their right to cancer care.
Dr. Duma: For one, I have a personal stake in this issue. Some of my family members have lapses in their visas and were faced with the challenges of finding health care while not having health-care insurance or a valid visa. So, undocumented workers facing a health crisis encounter huge financial burdens. It was very personal for me, and it highlighted the plight of millions of other Hispanics in the United States.
Other Challenges to Health Care
What are some of the other challenges to health care faced by undocumented people with cancer?
Dr. Olazagasti: First and foremost is the lack of health insurance coverage for undocumented immigrants under the current Affordable Care Act. I work and live in the New York City area, so I see the problem firsthand, given the large number of undocumented immigrants here. Only a tiny percentage of that population can afford private insurance with high out-of-pocket expenses. Moreover, most undocumented immigrants reside in a family with a full-time worker, but their access to employer-based coverage is difficult at best, because so many are working in low-wage jobs. This is why they need more than one full-time worker, which is yet another stressor in this difficult human dynamic.
When they look to me for help, especially because they see a common bond in our ethnicity, it truly hurts not to be able to help because of the financial barrier. On top of that, they also face language barriers and lack of the necessary medical literacy to navigate our very complex health-care system.
Dr. Duma: Preventive services such as Pap smears and mammograms are far less likely to be accessed by the undocumented population, which has severe downstream health consequences. One of the most difficult parts of this issue for oncologists is to have to to see significant delays in care and, at times, patients run out of time. This is anathema to what we were taught in medical school and why we became doctors in the first place.
Lack of Health Insurance: Real-World Impact
Do we have data to quantify the real-world impact that a lack of health-care insurance may have on undocumented patients with cancer?
Dr. Olazagasti: Despite the large number of immigrants in the United States, to my knowledge, the federal government doesn’t maintain a data bank that could help answer that question. However, we do know from epidemiologic data that Hispanic Americans have poorer cancer care outcomes than their White counterparts, so it is not difficult to extrapolate from that data that undocumented Hispanics with cancer have even poorer outcomes yet. Further, along with the challenges of access, we know from studies that underprivileged populations risk having lower quality of services, which we can safely assume is even more problematic in the undocumented population.
Dr. Duma: I have worked with large cancer databases, which are largely generated by government insurance records, and they do not include undocumented workers. In effect, these millions of people who are doing very hard work, sometimes for generations, essentially become ghosts in our health-care delivery system.
Personal Experience With Cultural Bias
What has your experience been like as Latinx oncologists practicing in the United States?
Dr. Olazagasti: I went to a bilingual school when I grew up in Puerto Rico and anticipated an easier transition when I came to the States. However, along with the good experiences of the oncology community, I had a bit of a rough initiation, enduring remarks about my accent, and other cultural biases. I want to be a good role model for young Latinx who come into the field. All in all, there are far more highs than lows.
Dr. Duma: I’ve faced the cultural stereotyping that many Hispanics and particularly Latinx physicians endure: surprise at how smart I am or being called sir with the assumption that I am a man. Microaggressions can break you down if you let them, but being an oncologist is about caring for patients with cancer, so that is where my focus remains.
DISCLOSURE: Dr. Olazagasti reported no conflicts of interest. Dr. Duma has served as a consultant or advisor to AstraZeneca and Inivata.