Introduction

This article examines how immigrant serving organizations (ISOs) in three U.S. southern states (KY, NC, SC) responded to the needs of immigrant and refugee community members in the early months of the COVID-19 pandemic. ISOs play a crucial brokerage role in helping immigrants access health-related information and other important resources [1]. In addition to providing medical care, community health workers [2], urgent response groups [3], and federally qualified health centers [4] often help vulnerable communities to access language services, transportation, and nutrition. These services have been shown to address key predictors of contracting COVID-19 [5]. Prior studies emphasize the particular role that ISOs play in “new destination” areas like the U.S. South and Southeast where state and municipal governments have responded to some of the fastest growing immigration population rates in the United States by enacting both welcoming and anti-immigrant laws [6, 7].

Throughout our interviews, the ISO leaders we spoke to emphasized that key aspects of their approach to addressing the needs of immigrant community members in the early days of the COVID-19 pandemic were shaped by Trump administration immigration policy reform efforts in the months leading up to the pandemic. We structure our findings around three Trump administration policy shifts that our respondents pointed to as key to shaping their perceptions of immigrant’s needs in the early days of the pandemic, as well as their efforts to address these needs: (1) the expansion of grounds deeming visa and permanent status petitions inadmissible based on the likelihood of the applicant becoming a “public charge;” (2) the proposed addition of questions related to immigration status in the 2020 US census; and (3) the reduction in annual refugee admissions caps. We conclude by discussing what several interviewees described as concerns about the long-term cost of organization flexibility, whereby an organization’s ability to be “flexible” and “nimble” in response to successive crises—in this case immigration policy uncertainty and the COVID-19 pandemic—may also inhibit long-term organizational stability.

Methods

Participants

The data for this article come from a larger mixed-methods study of immigrant access to healthcare in the U.S. Southeast during the COVID-19 pandemic. We interviewed a purposive sample of 31 clinics and social service organizations in a subset of three southeastern states: KY, NC, and SC. Our sampling approach targeted executive directors and program managers who help immigrants access healthcare services. Interviewing organizational leaders (rather than case managers or front-line staff) enabled us to ask a range of questions regarding organization capacity, client outreach, take-up rates, and other related topics. While the larger study can benefit from including interviews with immigrant clients, our focus here is on organization-level questions related to capacity and adaptation.

We selected these three states for several reasons. First, they vary in ways that are important for our study. KY and SC are both primarily rural states while NC is home to one of the largest metropolitan areas in the South (Charlotte). Given that clinics and nonprofit social service organizations face distinct challenges in rural, suburban, and urban areas [8], we assumed that organizational infrastructure—as well as outreach strategies, funding and capacity—would differ across the three states. Second, we selected these three states because they share certain characteristics in common as immigrant new destinations. The immigrant population in each state is relatively small, but consistent with other new destinations it has grown significantly since 2000 and is quite diverse. For example, immigrants make up only 5% of SC’s population but they increased in number by 121% from 2000 to 2018 [9]. Similar trends are reflected in the other two states. Mirroring national averages, Latinx immigrants make up about 50% of all immigrants in NC and SC, but slightly less (40%) in KY [9]. Due to its relatively large refugee resettlement program, African-origin and Asian immigrants in KY are overrepresented relative to their share of the immigrant population nationally [9]. Third, legislatures in all three states have proposed or passed state-level laws that directly and indirectly target immigrant communities and influence processes of immigrant integration.Footnote 1 While federal immigration policy determines who can enter the country, state and local governments enact hundreds of policies each year that influence the opportunities and resources available to immigrants once they arrive. Variation in state and local policies has created a dynamic patchwork of immigrant receiving contexts across the country [10]. Depending on their legal status immigrants in some places may have access to driver’s licenses and in-state tuition at public universities, for example, while local laws in a neighboring state are more restrictive. Thus, while the three states in this study are not representative of the U.S. South or of all immigrant new destinations, they reflect a range of conditions which provide an important starting point for exploring the questions we address in this article in this region.

Data Collection

Drawing on existing directories of social service organizations in the counties where immigrants tend to concentrate in each state, we sent recruitment emails to 75 organizations. We also asked respondents to refer us to other ISOs and health clinics in the area. We interviewed 31 respondents (NKY=9, NNC=9, NSC=11). Interviews lasted approximately 30 min and were conducted over the phone from June-September 2020 using a semi-structured interview guide consisting of eleven key questions. Open-ended prompts asked ISO leaders to reflect on the perceived needs of immigrant and refugee clients amid the COVID-19 pandemic and how their organizations had responded to meet these needs (How have the immigrants you serve been impacted by the COVID-19 pandemic? How has your organizations responded to these needs?). All interviews were audio-recorded and professionally transcribed. The contents of each interview were documented in memos. No statistical analyses of interview transcripts were performed.

Analysis

We utilized thematic content analysis to code the transcribed interviews. Based on the semi-structured interview guide, we developed a codebook to categorize major themes, including the effect of the COVID-19 pandemic on clients and organizations, organizations’ responses to the COVID-19 pandemic, and factors that influence service access and utilization. To bolster inter-coder reliability, two team members conducted independent line-by-line coding of each interview. During team meetings, each member reviewed their coding schemes to ensure that codes were applied consistently.

Results

Dramatic programming shifts related to the COVID-19 pandemic were the norm among the ISOs included in our study. In particular, many of the organizations we talked to switched to online or phone-based programming and shifted towards meeting basic material needs, such as food distribution and rent assistance. When we asked the director of a medical student-run health clinic in North Carolina to briefly describe the clinic, she responded, “Which clinic are you talking about? Pre-COVID-19 or post-COVID-19?” Over the first months of the COVID-19 pandemic, it felt as if the clinic had transformed into something entirely different. Before this period, she explained, much of the clinic’s work focused on addressing chronic illnesses like asthma, diabetes, and high blood pressure. The “post-COVID-19 clinic,” meanwhile, primarily distributed masks, canned foods, and personal hygiene items to struggling community members. Other participants expressed similar shifts. The director of a refugee resettlement agency in North Carolina, for example, explained that, “We’ve […] completely overhauled all of our activities to prioritize people’s most emergent needs and keep the crisis at the forefront of things.”

Across our interviews, ISO directors stressed the ways that Trump administration immigration policies and immigration policy rhetoric in the months leading up to the pandemic shaped their ability to make these programming shifts, both positively and negatively. In what follows we outline how organizations’ responses to three Trump-era immigration-related policies—the “public charge” rule, efforts to add a question about immigration status to the U.S. census, and the reduction of annual refugee admissions caps—shaped the ability of ISOs to meet the immigrants’ needs in the early days of the pandemic. We then describe what several respondents described as a paradox of “being nimble.” On the one hand, the ISO directors that we spoke to described how their efforts to respond to immigration policy uncertainty prepared them to “be nimble” in the early days of the pandemic. On the other hand, interview respondents also expressed concern that this organizational flexibility reflected organizational precarity, whereby responding to successive crises left organizations unsure about sustainability and their ability to enact long-term planning.

Policy Precursor #1: Expanded Grounds for “Public Charge” Inadmissibility

The first policy precursor that shaped the ability of ISOs to meet immigrants needs in the early days of the pandemic was the Trump administration’s “public charge” rule, announced in September 2018, which would have expanded the number of reasons an immigrant can be denied a visa or permanent residence based on their likelihood of becoming a “public charge” [11]. Under the proposed changes, accessing the Supplemental Nutrition Assistance Program (SNAP) and other state-based cash assistance programs could have been grounds for denial of lawful permanent resident status in the future. Several of our respondents associated hesitancy around accessing health care in the early days of the pandemic with a broader chilling effect created by the public charge rule. As the director of an agency that supports immigrant and refugee families explained, “One of the things that we’ve noticed is that because of the public charge [rule], even folks that are not undocumented are worried about accessing public health services because of how it might impact their status.” Other respondents highlighted their attempts to carefully explain that while the public charge rule had been suspended during COVID-19, it might be implemented again, especially if Donald Trump were to be reelected. The director of a health clinic in South Carolina with a significant proportion of Latinx clients, for example, explained how her efforts to assuage patients’ hesitancy around accessing public benefits like food stamps shaped how she talked with patients about the risks associated with COVID-19. In particular, she was careful to clarify that things could very well change: “I think it’s a distrust of the climate right now. And I’ll admit even in my own communications to people about [SNAP] is that it should not be used against you. I tried not to say that it absolutely will not because we just—things have turned on a dime before to the detriment of our clients.” At the same time that ISO directors associated policy uncertainty surrounding the Trump administration’s “public charge” with increased hesitancy around accessing social services, confronting this policy uncertainty aligned in important ways with their efforts help immigrant clients navigate other uncertainties related to the evolving COVID-19 pandemic.

Policy Precursor #2: The Trump Administration’s Proposed Census Reforms

The second policy precursor that impacted the ability of organizations to meet immigrant’s needs in the early days of the pandemic was the Trump administration’s March 2018 announcement that a question about citizenship status would be added to the 2020 census [11]. After the proposed change was overruled in the summer of 2019, organizations scrambled to update community members and promote census participation given the potential long-term impact of an undercount on political representation and local-level funding for public services. As the director of an organization in Kentucky explained, “I turned my staff totally towards trying to reach out to our international communities, to help support responding to the census” in the months leading up to the pandemic. As the director went on to explain, this Census-related canvassing work prepared organization staff to conduct door-to-door outreach efforts in the early days of the pandemic when families were hesitant to leave their homes. Other organizations we spoke to also mentioned integrating COVID-19 related outreach efforts with census participation drives. For example, a program coordinator associated with another Kentucky-based organization explained, “Coming up very soon, we’re going to start reaching trailer parks and neighborhoods where people live so we can not only share masks and, you know, hand sanitizers, but we can also provide information about free testing while we help them fill out the census.” Damage control outreach efforts associated with the Trump administration’s proposed census changes, then, prepared organizations to conduct similar rapid-response outreach efforts aimed at sharing resources and information with immigrant community members.

Policy Precursor #3: Reductions in Refugee Admissions

The third relevant policy precursor for interview respondents was the Trump administration’s reduction in the number of annual refugee admissions, which lowered from an annual ceiling of 85,000 when Trump entered office in 2016 to 16,000 in 2020 [11]. For resettlement organizations included in our sample that receive funding based on the number of refugees they serve annually, these reductions had a major impact on their ability to provide services. As the director of an organization in North Carolina that works with refugee newcomers explained, “One of the challenges has been that a lot of our federal funding is per capita based on refugee arrivals. And obviously, with travel restrictions and few or no refugee coming into the country, that has created some issues.” The director of a different North Carolina-based refugee resettlement organization explained that the agency had experience a 95% reduction in federal funding since 2016. Interviewees mentioned responding to these reductions in a variety of ways. One director mentioned how the reduction in refugee admission led the organization to take an “innovate or die” approach that has involved expanding services for “immigrants of other statuses,” including undocumented individuals. Other organizations focused on shifting their programming to meet the needs of “secondary migrants” (refugees who move to a new city from their original resettlement site) or on transitioning staff members towards grant-funded projects that serve other immigrant groups. As the director of an organization that works closely with refugee resettlement agencies recounted, “Today, because of cutbacks from the national administration, [refugee-serving organizations] have gotten a lot of grants to provide services to other immigrant populations. Now they have a bigger legal staff, they have social workers, the have domestic violence assistants, much bigger [staff] than mine.”

Policy Uncertainty and the Paradox of “Being Nimble”

The above examples illustrate how Trump-era immigration reforms and related policy uncertainty laid the groundwork for organizations to pivot quickly in response to COVID-19 related disruptions. In this section, we discuss how interviewees understood the relationship between immigration policy uncertainty and what several respondents described as a paradox of “being nimble.” Several of the ISO directors that we spoke to celebrated their ability to pivot quickly to the rapidly shifting needs of immigrant community members in the early days of the pandemic, something many organizations already had experience with as a result of Trump administration immigration policy shifts. The director of an organization that works with refugee and immigrant newcomers in North Carolina, for example, who described the pandemic as part of a broader period of time that “has laid bare the cracks in the system,” commented that moving forward through the pandemic and beyond, “we’ll probably be more […] nimble and more flexible in terms of our services.” While other agency directors were similarly proud of their ability to meet the evolving needs of immigrant community members, they also expressed concern about funding dynamics that prioritize short-term flexibility over long-term organizational stability. One ISO director in North Carolina, for example, explained that most funders are “providing just a few months of funding at a time, because they want to stay sort of nimble to the context.” While she understood this funding stance, she also explained that, “It certainly fosters some challenges for, like, long-term organizational stability and looking out beyond, you know, the next few months.” The director of a refugee resettlement agency in Kentucky expressed a similar sense of concern surrounding organizational flexibility: “As a smaller agency it’s easier for us to make changes. […] one of the negatives is that we don’t have the backing of a larger organization.” Finally, while some organizations saw an influx of new funding streams in the early days of the pandemic, these additional funds paled in comparison to larger organizational costs and losses in revenue that resulted from sudden programming and fundraising stoppages. As the director of an agency that provides health care and workforce development programming for immigrant communities in South Carolina explained, “Our donations have come way down. A lot of special events that we wanted to have to raise money, we had to cancel that. So, for the last two months, we’ve been operating in the red. […] I’m sure it’s gonna be that in the next 12, 18-month period, some nonprofits will have to fold.”

Discussion and Implications

The organizations we spoke to played a crucial public health role in the wake of the COVID-19 pandemic. ISOs included in our sample facilitated access to testing, consulted with state and municipal leaders to facilitate informational outreach campaigns, and, perhaps most important of all, they funneled resources to immigrant communities that were otherwise excluded from federal relief programs. Having already made programming changes related to Trump administration immigration policy uncertainty, many of the organizations that we spoke to quickly shifted to providing basic forms of relief in the early days of the pandemic, providing a crucial lifeline for immigrant community members. However, the ISO directors we interviewed also expressed concerns about the relationship between this adaptability and broader organizational precarity, especially in new destination areas like KY, NC, and SC where organizations are less likely to be institutionally embedded and more likely to face a more inconsistent funding landscape. While we have focused in this paper on federal policy impacts in three states that are representative of growing immigrant populations in “new destination” areas such as the South and Southeast, future research might delve more deeply into how state- and municipal-level policy contexts (“welcoming cities” situated in states with restrictive immigration policies, for example) shape ISO service provision.

Understanding the relationship between organizational flexibility and long-term organizational wellbeing has important implications for public health practice and research. The COVID-19 pandemic is not the first major disruption that immigrant communities have faced, and it will not be the last [12]. Some respondents pointed to parallels between the COVID-19 related upheaval and earlier natural disasters. The director of a food pantry along the South Carolina coast, for example, noted that the organization first developed a network of bilingual volunteers to meet the needs of immigrant residents and construction workers who flocked to the area in search of work after Hurricane Matthew in 2016. Relatedly, local ISOs have played particularly essential roles in disaster responses (e.g., Hurricane Katrina) to diverse individual needs, especially when government agencies could not immediately respond [13], or in the context of heightened enforcement of federal immigration removal policies [14]. The COVID-19 pandemic has provided further evidence for the important public health role that ISOs play, especially in crisis moments.

Trump-era policies and the anti-immigration sentiments of some politicians during the pandemic have likely intensified mistrust of mainstream institutions among immigrant communities [15]. Despite such political uncertainties, ISOs undertook substantive efforts to meet the emerging needs of local immigrant communities during the COVID-19 pandemic based on their knowledge of community conditions and local networks. Amid widespread distrust of mainstream systems experienced by immigrants, local ISOs will be crucial to promoting access to health and social services for immigrant communities as the destructive wake of COVID-19 spreads.