Year: 2018

The Power of Radium

Heather Roesch is a biochemistry major at Grinnell College. After graduation (2018), she will be pursuing a Masters in Forensic Science. The discovery of radium in 1998 by Marie and Pierre Curie changed the American public’s view about both scientific limitations as well as public health. When radium was first extracted from pitchblende, a uranium… Read more The Power of Radium

Vaccines: How Medical Innovation Changed the World Around Infectious Disease

Rob McCarty (2018) is a biology major at Grinnell from Hudson, Florida with a particular interest in molecular biology. He played football each of his four years and plans to enter research in cancer biology after Grinnell. It is hard for us today to imagine a time when a child’s first trips to the doctor… Read more Vaccines: How Medical Innovation Changed the World Around Infectious Disease

The History of and Current (In)accessibility of Abortions in the United States

Meta Williams (2018) is a Biological Chemistry and Spanish double major at Grinnell College. Outside of academics, she runs, hikes, bakes and cooks; she prides herself on her ability to make vegetables appealing to non-vegetable eaters. Meta will be joining the AmeriCorps after graduation, and hopes to eventually attend medical school.

Abortion. Think about it: abortion. As an issue always on the forefront of the American collective conscious, abortion is about as loaded of a word as one can find. So what do you think when you think “abortion”? You may use words like “prolife” or “prochoice”. You may think “good” or “bad”, “immoral” or “necessary”.

You probably, however, did not think about “accessible”. Yet, the accessibility of abortion services and abortion clinics in perhaps one of the most important aspects of the abortion debate. Who can get one? How is it paid for? Where do you go to get one? These are all questions pertaining to the accessibility of abortive services and centers that perform abortions.

In 1973, the landmark US Supreme Court case of Roe v. Wade recognized womyn’s constitutional right to abortion [1].  In subsequent years, the Supreme Court has upheld that decision, ruling that a state cannot ban abortion before the point at which a fetus can survive outside of the uterus. They also ruled that the restriction on abortion after this period may be overridden if the life of the womon is at risk, and that it is unconstitutional to place “undue burden” on a womon seeking an abortion [2].

Despite these laws, which have been repeatedly tested through our judicial system, Americans still are grappling with what to do about abortion. As of January 1st of this year, all but 10 states sported one or more of five major obstructions to abortion. In this post, I will break down each of the five so-called “Major Obstructions” and provide evidence that demonstrates that we, as a society, are not only failing the Roe v. Wade ruling, but also the thousands of womyn searching for an alternative to a pregnancy they cannot support, be it biologically, socially, financially or emotionally [3].

Before delving into these specific obstructions, however, I think it would be beneficial to review the pre-legal history of abortion in the United States. As Rachel Benson Gold and Megan K. Donovan report in their article “Lessons from before Abortion Was Legal”, the “history of abortion underscores the reality that the procedure has always been with us, whether or not it was against the law” [4].

In the 1700s and through the mid-1800s, abortion was permitted by states. In fact, before the criminalization of the procedure, aborting an early pregnancy was, actually, legal until an event called “quickening”, which was when the pregnant womon was able to feel the movements of the developing fetus. This event normally fell around four months into the pregnancy, and interestingly, at this point in history, not even the Catholic Church believed that a human life existed before quickening [5].

Early abortion legislature began to pop up in the 1820s and 1830s, but rather than to control womyn’s access to abortions, the laws were more poison control measures, set in place to control the spread of dangerous abortifacient drugs, which were dangerous to the womyn that imbibed them [6].

Despite these regulations, however, abortion was a booming practice during the first half of the nineteenth century. Estimates show that “between 1800 and 1830, one abortion occurred for every twenty-five to thirty births”, but that by the 1850s, “the proportion had increased to as many as one abortion per every five to six live births” [7].

It was only in the mid-1800s that the procedure fell out of legal favor, due, in part, to the American Medical Association’s (AMA) desire to consolidate medical power in the United States [8]. By 1900, abortion’s fall from grace was complete, as most every state viewed abortion to be a crime.

This increase in abortion-related legislation, however, was met by a lack of contraceptive options, leaving womyn with few ways to prevent unwanted pregnancies. As John D’Emilio and Estelle B. Freeman report in their book Intimate Matters: A History of Sexuality in America, “women [attempted to] induce miscarriage themselves or seek abortions. In the early nineteenth century, and in rural areas for many later generations, herbal and home remedies for terminating unwanted pregnancies continued to be passed on through oral tradition… surgical procedures, such as the use of a probe by a doctor or by a pregnant woman herself, were available but dangerous” [9].

By the 1960s, many abortion-seeking womyn were left to utilize underground abortion services, such as Chicago’s Jane Collective, which from 1967 to 1972, had helped facilitate up to 15,000 illegal abortions [10]. Still, many of these services, not to mention self-performed “coat-hanger abortions”, were not safe. In the 1950s and 60s, “between 200,000 and 1.2 million women underwent illegal abortions each year in the US.” In 1965, “illegal abortion accounted for an estimated 17 percent of all officially reported pregnancy-related deaths”. Remember: that that number is for “officially reported pregnancy-related deaths” [11]. What about deaths that were put under another cause to preserve the reputation or legal status of a woman?

As recently as 2016’s Whole Woman’s Health v. Hellerstedt, the staggering number of abortion-related Supreme Court cases demonstrate the American public’s resistance to womyn’s right to abortion and have begun to chip away at the foundations of the Roe v. Wade ruling. In 2017, the Guttmacher Institute released a report that determined 15 obstructions to abortion, which were grouped into five barrier groups [12].

Travel-related logistical issues:

Due to the decreasing number of abortion facilities across the United States, womyn frequently must travel farther distances to get to clinics or facilities that can provide the services they need. S.C.M. Roberts et al.’s 2014 article “Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States” reports that “women also reported paying up to $2200 for out-of-pocket travel costs, with a median (mean) of $15 ($54). Women with first trimester abortions paid a median (mean) of $10 ($23) out-of-pocket travel costs, women 14 to less than 20 weeks paid $20 ($47; p < 0.01 compared with first trimester), and at or after 20 weeks $30 ($100; p < 0.001 compared with first trimester) [13].

System navigation issues:

Navigating the system, as well as the stigma associated with the United States’ abortion system, can be a major barrier for some womyn seeking abortion services. Kimport et al.’s 2012 article on abortion clinic structures and processes noted that although most womyn are satisfied with the abortion care they receive in clinics, factors such as the presence of protesters or the emotional constitution of the staff played a role in abortion access [14]. Kimport reports that “even with [the anticipation of protesters], these interactions with protesters increased women’s feelings of stigma, secrecy and shame”, and that the security measures in place to protect abortion-seeking womyn from protesters reportedly made some survey respondents uncomfortable [15].

Limited clinic options:

In the clinical research of abortion-providing facilities, there seem to be four types of locations: abortion clinics, non-specialized clinics, hospitals, and physicians’ offices. According to “Abortion Incidence and Service Availability in the United States, 2014”:  Abortion clinics are defined as non-hospital facilities in which half or more of patient visits are for abortion services, regardless of annual abortion caseload. Non-specialized clinics are non-hospital sites in which fewer than half of patient visits are for abortion services. Physicians’ offices are defined as facilities that provide fewer than 400 abortions per year…Physicians’ offices that provide 400 or more abortions per year were categorized as non-specialized clinics” [16].

Between 2011 and 2014, the abortion rate declined by 3-6% per year, while the total number of abortion facilities declined 3% over the same three years; however, the closings were most likely to be of heavy caseload abortion clinics, which provide 1,000-4,999 per year (26% of abortions) [17].

Financial issues:

Clients at Title X-supported facilities, which are involved in “ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals” are frequently young and low-income, a statistic that draws attention to the dire financial situations of many of these womyn and couples. [18, 19] In addition, 42% of abortions in the United States occur among women living below 100% of the federal poverty level (FPL) and 69% occur among women below 200% FPL [20].

A 2014 study determined that two-thirds of womyn seeking an abortion received some financial assistance assisting in the cost of their procedure, whether it was private insurance (7%), Medicaid (34%), and/or other organizations (29%) [21].

Still, twenty-nine percent of womyn seeking an abortion did not receive any financial assistance, which would be a tremendous financial blow, considering the median price of a first trimester abortion in 2014 was $490, with a range of $225 to $750 (mean of $497). However, the price increases to a mean of $860 for an abortion between 14 and 20 weeks; after 20 weeks the mean is $1874. These costs are for the procedure, only: womyn also must factor in transportation costs and the time and potential income lost from their daily lives, be it work, school or family care [22].

State or clinic restrictions:

Even though Roe v. Wade set a nation-wide ruling for abortion legislature, state-level abortion restrictions are making abortions more difficult to obtain. In 2013, Texas implemented targeted regulation of abortion providers, colloquially known as TRAP, laws that mandated that doctors who provide abortions have admitting privileges at local hospitals, and that clinics meet strict standards set for ambulatory surgical centers. These TRAP laws led to the closing of more than half of Texas’ abortion clinics, and although the Supreme Court overturned these regulations in 2016 and the decision was used several times in the next months to block similar laws in Alabama, Florida and Indiana, as of August, 2016, at least 24 states had enacted TRAP laws [23].

There are also state-level abortion restrictions that mandate longer waiting periods and limit facility availability, this issue is further complicated by the fact that most providers have limits on when in a pregnancy they will perform an abortion; womyn very early on or in their second trimester frequently have a difficult time finding facilities to help them [24].

Clearly, there are many efforts in place to attempt to prevent womyn from receiving the Constitutionally-sound care they need, and, arguably, deserve. Throughout the history of the United States, the relationship between the public, the state, the womon and abortion has experienced its fair share of trials and triumphs. Looking to the future, however, it would be impossible to say anything certain about the future of abortion in this country, except for the fact that the question of accessibility to this life-changing, and potentially life-saving, procedure will continue to be one of the major players in this debate.

 

Further readings

Levine, Phillip B., Amy B. Trainor and David J. Zimmerman. “The effect of Medicaid abortion funding restrictions on abortions, pregnancies and births.” Journal of Health Economics 15 (1996): 555-578.

Pollitt, Katha. Pro: Reclaiming Abortion Rights. Picador, 2014.

Roe v. Wade: Its History and Impact.” Planned Parenthood Federation of America, January 2014.

 

Endnotes

[1] In this paper, I will be spelling woman as “womon” and women as “womyn”; this is an intentional decision, based on my belief that abortion is a womyn’s health issue, and therefore should be a topic that womyn have power in. Utilizing these alternative spellings of the words cements that womyn are not dependent, nor should they be, on men or their opinions on what they can or cannot do with their bodies.

[2] “United States Abortion.” Guttmacher Institute. Last modified 2018. https://www.guttmacher.org/ united-states/abortion.

[3] Jerman, Jenna, Lori Frohwirth, Megan L. Kavanaugh, and Nakeisha Blades. “Barriers to Abortion Care and Their Consequences For Patients Traveling for Services: Qualitative Findings from Two States.” Perspectives on Sexual and Reproductive Health 49, no.2 (2017): 95-102.

[4] Gold, Rachel Benson and Megan K. Donovan. “Lessons from before Abortion Was Legal.” Scientific American September 2017.

[5] Reagan, Leslie J. When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973. University of California Press, 1997, 8-9, 25.

[6] Ibid., 42-43.

[7] D’Emilio, John and Estelle B. Freedman. Intimate Matters: A History of Sexuality in America. University of Chicago Press, 1988.

[8] Reagan, 14-18.

[9] D’Emilio and Freedman, 65.

[10] King, C.R., “Calling Jane: the life and death of a women’s illegal abortion service.” Women’s Health 20 no. 3. (1993): 75-93.

[11] Gold and Donovan, Online.

[12] Jerman, Frohwirth, Kavanaugh and Blades, 98.

[13] Roberts, S.C.M., Heather Gould, Katrina Kimport, Tracy A. Weitz, Diana Greene Foster. “Out-of-Pocket Costs and Insurance Coverage for Abortion in the United States.” Women’s Health Issues 24, no. 2 (2014): e211-e218.

[14] Kimport, Katrina, Kate Cockrill and Tracy A. Weitz. “Analyzing the impacts of abortion clinic structures and processes: a qualitative analysis of women’s negative experiences with abortion clinics.” Contraception 85 (2012): 204-210.

[15] Ibid., 207.

[16] Jones, Rachel K. and Jenna Jerman. “Abortion Incidence and Service Availability In the United States, 2014.” Perspectives on Sexual and Reproductive Health 49, no. 1 (2017): 17-27.

[17] Ibid., 20.

[18] “About Title X Grants.” Office of Population Affairs, United States Department of Health and Human Services, March 6, 2018. https://www.hhs.gov/opa/title-x-family-planning/ about-title-x-grants/index.html.

[19] Frost J.J., L.F. Frohwirth and M.R. Zolna. “Contraceptive Needs and Services, 2013 Update.” New York: Guttmacher Institute, 2015.

[20] Jones, R. K., & Kavanaugh, M. L. ”Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion.” Obstetrics and Gynecology 117 no. 6 (2011) 1358–1366.

[21] Roberts, S.C.M., L. Fuentes, R. Kriz, V. Williams, U.D. Upadhyay. “Implications for women of Louisiana’s law requiring abortion providers to have hospital admitting privileges.” Contraception 91 (2015): 368-372.

[22] Ibid.

[23] Jones and Jerman, 19.

[24] Jones, Rachel K. and Kathryn Kooistra. “Abortion Incidence and Access to Services in the United States, 2008.” Perspectives on Sexual and Reproductive Health 43, no. 1 (2011): 41-50.

 

Beside The Golden Door

Leah Barr is a fourth year Gender, Women’s, and Sexuality Studies major at Grinnell College from Evanston, IL. Her maternal great grandparents met on the boat to Ellis Island. Leah plans to spend the next few years in pursuit of her lifelong goal of becoming a library curmudgeon. At the base of the Statue of… Read more Beside The Golden Door

DO-ing Medicine: Women in Osteopathic Medicine

Katie Ackerman is a fourth year biochemistry major at Grinnell College.  In the fall she will be attending Pacific Northwest University School of Health Sciences to pursue an osteopathic medical degree.  Apart immersing herself in science, Katie does lots of photography, pottery, and running. From the first woman to practice medicine in the United States… Read more DO-ing Medicine: Women in Osteopathic Medicine

The Color of Forced and Coerced Sterilizations

Taylor Burton [2018] is a sociology major, writing mentor, and student research assistant at Grinnell College. Through her studies, Burton primarily focuses on racial and class oppression within the context of neoliberalism and capitalism. Outside of her academics, she participates in social justice activism through various student organizations at Grinnell College. An often forgotten history… Read more The Color of Forced and Coerced Sterilizations

A Crisis We Would Rather Avoid: Water Quality and Public Health in the United States

Thomas Aldrich is a third year history and religious studies double major at Grinnell College. In his free time he enjoys singing, riding his bike around campus and out of town, and advocating for stronger government oversight. For those of us who have lived our entire lives with a safe, secure water supply, the idea… Read more A Crisis We Would Rather Avoid: Water Quality and Public Health in the United States

The Fleeting Memories of Immigrants: Dementia in US Immigrants

Andrej Ćorković (2018) is a student at Grinnell College majoring in Chemistry with a concentration in European Studies. His main academic interests involve organic chemistry and the synthesis of new molecules, and he hopes to contribute to the medical field one day. When not in class, he is playing basketball, soccer, YuGiOh, or FIFA.

A land of freedom. A land of opportunities. A land of hope. The United States of America is known for all these qualities and more. People from all corners of the world move to America in search of safety, freedom, hope, and so on. Yet, many immigrants arrive with few strategies of how to reach their dreams once arriving in the new country. My family and I are examples of such immigrants. We moved to America 19 years ago with the intentions of building a better future. We have faced constant struggles throughout our stay in America including language barriers and general knowledge about how America operates among others. Like most immigrants, health care is something that we avoid. However, in the past four years, my family has been searching for the right form of health care to address my mother’s dementia. Like many of our counterparts, we do not know the resources available to help. In addition to general health care, finding treatment and help for mental health conditions, like dementia, among immigrants is grim because of immigrants’ lack of information and their language barriers. Following 1996, new legislation has been passed to help migrants find resources in more accessible and reliable methods.

My family and I immigrated to the United States in 1999. Although I have little recollection of the health of my family at the young age of four, I have been led to believe that we arrived happy and healthy. We were fortunate to have avoided going to doctors or hospitals often in the early years as the “1996 federal welfare reform law (Personal Responsibility and Work Opportunity Reconciliation Act, or PRWORA) restricted Medicaid eligibility of immigrants, so that those admitted to the United States after August 1996 cannot receive coverage, except for emergencies, in their first five years in the country.” Being new to the country, many legal immigrants are eligible for Medicaid, but the new law prevented many new immigrants from obtaining insurance coverage. Furthermore, both insured and uninsured immigrants have less access to medical care compared to native-born citizens [1]. As cited in the opening paragraph, this may be due to lack of information, language barriers, and so on.

There have been recent efforts to support immigrants with new legislation being proposed that would “give states the option to restore immigrants’ eligibility for Medicaid and SCHIP (State Children’s Health Insurance Program) for children and pregnant women.” Other pundits suggest that jobs should develop methods to offer health insurance for immigrant families. However, studies show that immigrants were offered health insurance less often than native-borns [2]. This is simply unfair. Thus, some policy changes that should transpire are: (1) to expand health insurance coverage, (2) to address limited English proficiency, (3) to expand and strengthen the safety net infrastructure, and (4) to revise PRWORA [3]. During the Obama administration, many of these suggestions were addressed with Obamacare being the most significant. However, more still needs to be done to assist immigrants.

Immigrants are often recognized as a vulnerable population, “a group at increased risk for poor physical, psychological, and social health outcomes and inadequate health care.” Some of the factors that help to contribute to this vulnerability include their socioeconomic background, immigration status, residential location, PRWORA, English proficiency, and stigma and marginalization. Of these six factors, I suggest that English proficiency has the greatest impact. Coming to America, my family spoke only Croatian and German. We did not know many people in America that we could communicate with, and translators were a requirement in almost all situations. Going to the doctor was understandably difficult, especially since finding Croatian translators was even more difficult.

Many immigrants experience similar situations. Limited English proficiency typically results in families with no insurance, fewer physician visits, lower quality of care, and worse patient safety [4]. However, patients with interpreters are more likely to be curious about their care and use preventive services. Thus, improving access to interpreters may be a large aspect in improving health care among immigrants. Access to the preventive services would have great benefits because it “can lead to future lowered utilization and expenditures of non-preventive services, and… it seems efficient and beneficial to prioritize the provision of preventive care to immigrants in public funding of medical care” [5]. Not only would increasing the availability of interpreters result in more informed patients, but it would save the patients and government money in the future. As I have stressed, a lack of information of available health care resources for immigrants is a large part of their difficulty in finding appropriate health care.

When my family moved to America, we moved to Rockford, IL because my father knew friends there. Like most immigrants, my dad “[began] gathering information about [his] receiving society and locating possible social ties that can be quickly mobilized to help absorb the initial shock of migration” [6]. This absorption is vital for the first few years when an immigrant moves; however, after a few years, the immigrant is expected to determine information for themselves. Once I entered elementary school, I became my parents’ informant. I was learning English at school at a faster rate than my parents, so it was easier for me to learn about landlines, Internet service, and much more. However, even to this day, other aspects of American society are still foreign to us such as politics and health care. This brings me to the matter at hand: dementia in immigrants.

Mental health is a difficult subject to discuss, and dementia is one of those conditions that many people cannot define. Dementia is “a chronic or persistent disorder of the mental processes caused by a variety of brain diseases or injuries marked by memory disorders, personality changes, and impaired reasoning” [7]. Dementia is essentially a death sentence with no cures and limited treatments. Those with dementia first start to forget small things like words, but then they forget how to use everyday objects like spoons and forks, and they can get to the point where they do not know who their own children are. This is the case for my mother, who suffers from dementia.

Even though dementia is so devastating and painful to the patient and the families of the patient, it is also highly preventable. According to a study by Benjamin K.P. Woo and Jamie O.P. Chung, “Chinese-American immigrants may not seek help for their cognitive impairments out of fear of ‘losing face.’” Although their research focuses on Chinese-American immigrants, the shame concept can be applied to all immigrants. People move to America hoping for success and happiness, but a disease like dementia can make immigrants feel like lost potential and a waste of space. Many areas of the individuals’ lives are affected, ranging from employment to social relationships. One of the key aspects in helping dementia treatment is community support, so public participation is vital to overcoming dementia stigma, but a lack of understanding of dementia among immigrants leads to social exclusion and discrimination [8]. A greater understanding and knowledge of the disease can help destigmatize dementia and offer patients an essential support network. Being an immigrant, my mother’s social network is not very expansive, and thus, she receives little support from her family and friends. Therefore, a better educated public will result in a greater support network that can help patients suffering with dementia and the family that cares for them.

Furthermore, the culture of the individual afflicted with dementia can have a huge impact on the way they respond to treatment. This has been evident with my mother. We have gone to several suggested resources to seek help, but most of the resources conflict with our cultural standards. We want someone to come to our house to interact with my mom for a couple of hours, but most resources suggest stuffing her in a nursing home or institution. In Mary R. Janevice and Cathleen M. Connell’s article, they argue that a “unique set of caregiving conflicts may arise in immigrant cultures when family members are at different levels of acculturation and have correspondingly different values or beliefs related to caregiving” [9]. The difficulty of acculturation is not only related to finding caregiving and help, but the individual with dementia begins to “revert to the more traditional end of the acculturation continuum” [10]. My mom believes that she is living in Bosnia, and she does not speak English at 5% of the level that she used to be capable of. She is reverting to the traditional culture that she grew up with.

Finally, many studies suggest that multilingualism helps delay the onset of Alzheimer’s Disease and dementia [11, 12, 13]. Immigrants tend to be bilingual upon entering the US, and this may be one of the reasons that dementia rates in immigrants is lower than that of native-borns [14]. However, immigrants who learn English once they arrive in America may be more prone to forgetting it and having more difficulty communicating as has been the case with my mom. She has essentially reverted to monolingualism in Croatian. Thus, being bilingual or better does not necessarily support the dementia preventative care.

Upon entering America, many immigrants have a desire to improve their lives, help their families, and reach their dreams. Once they have arrived, however, there are many trials and tribulations they must overcome. One such provision is health care. Immigrants have difficulty acclimating to their new society and are thus often viewed as a vulnerable population. This vulnerability leads to more difficulty in accessing the health care necessary for them, resulting in less information about American health care, particularly in mental health. Individuals with mental health problems such as dementia have more difficulty finding treatment and care due to differences in language and cultures. However, educating the public and immigrants can lead to better understanding of diseases, the health care system, and the available resources to help get immigrants and native-borns the necessary treatments they deserve.

Notes

[1] Leighton Ku, Sheetal Matani. “Left Out: Immigrants’ Access to Health Care and Insurance,” Health Affairs 20, no. 1 (2001) 247, 253.

[2] Ibid. 254.

[3] Kathryn P. Derose, Jose J. Escarce, Nicole Lurie. “Immigrants and Health Care: Sources of Vulnerability,” Health Affairs 26, no. 5 (2007) 1264-1265.

[4] Ibid. 1258, 1259-1263.

[5] Xu, Ke Tom, Tyrone F. Borders. “Does Being an Immigrant Make a Difference in Seeking Physician Services?” Journal of Health Care for the Poor and Underserved 19, no. 2 (2008) 388.

[6] Kuo, Wen H., Yung-Mei Tsai. “Social Networking, Hardiness and Immigrant’s Mental Health,” Journal of Health and Social Behavior 27, no. 2 (1986) 135.

[7] “Dementia.” English Oxford Living Dictionary. https://en.oxforddictionaries.com/definition/dementia (accessed April 20, 2018).

[8] Woo, Benjamin K.P., Jamie O.P. Chung. “Public Stigma Associated with Dementia in a Chinese-American Immigrant Population,” Journal of the American Geriatrics Society 61, no. 10 (2013) 1832-1833.

[9] Janevic, Mary R., Cathleen M. Connell. “Racial, Ethnic, and Cultural Differences in the Dementia Caregiving Experience: Recent Findings,” The Gerontologist 41, no. 3 (2001) 345.

[10] Day, Kristen, Uriel Cohen. “The Role of Culture in Desigining Environments for People with Dementia: A Study of Russian Jewish Immigrants,” Environment and Behavior 32, no. 3 (2000) 363.

[11] Alladi, S., Thomas H. Bak, Vasanta Duggirala, et al. “Bilingualism delays age at onset of dementia, independent of education and immigration status,” Neurology 81, no. 22 (2013) 1938-1944.

[12] Chertkow, Howard, Victor Whitehead, Natalie Phillips, et al. “Multilingualism (But Not Always Bilingualism) Delays the Onset of Alzheimer Disease: Evidence From a Bilingual Community,” Alzheimer Disease & Associated Disorders 24, no. 2 (2010) 118-125.

[13] Craik, Fergus I.M., Ellen Bialystok, Morris Freedman. “Delaying the onset of Alzheimer disease,” Neurology 75, no. 19 (2010) 1726-1729.

[14] Xu, “Seeking Physician Services?” 384.

For Further Reading:

DesMeules, Marie, Jenny Gold, Arminee Kazanjian, et al. “New Approaches to Immigrant Health Assessment,” Canadian Journal of Public Health 95, no. 3 (2004) I-22-I-26.

Guillermina, J., Douglas S. Massey. “Immigrant Health: Selectivity and Acculturation, “IFS Working Papers 23, no. 4 (2004) 1-47.

Kirmayer, Laurence J., Lavanya Narasiah, Marie Munoz, et al. “Common mental health problems in immigrants and refugees: general approach in primary care,” Canadian Medical Association Journal 183, no. 12 (2011) E959-E967.