The Health of Newcomers

Immigration, Health Policy, and the Case for Global Solidarity

Patricia Illingworth, Wendy E. Parmet

• Publisher: NYU Press
• Year: 2017
• ISBN:
  9780814785973
• Topic: Sciences sociales
• Subtopic: Émigration et immigration

Immigration and health care are hotly debated and contentious issues. Policies that relate to both issues—to the health of newcomers—often reflect misimpressions about immigrants, and their impact on health care systems. Despite the fact that immigrants are typically younger and healthier than natives, and that many immigrants play a vital role as care-givers in their new lands, native citizens are often reluctant to extend basic health care to immigrants, choosing instead to let them suffer, to let them die prematurely, or to expedite their return to their home lands. Likewise, many nations turn against immigrants when epidemics such as Ebola strike, under the false belief that native populations can be kept well only if immigrants are kept out. In The Health of Newcomers, Patricia Illingworth and Wendy E. Parmet demonstrate how shortsighted and dangerous it is to craft health policy on the basis of ethnocentrism and xenophobia. Because health is a global public good and people benefit from the health of neighbor and stranger alike, it is in everyone’s interest to ensure the health of all. Drawing on rigorous legal and ethical arguments and empirical studies, as well as deeply personal stories of immigrant struggles, Illingworth and Parmet make the compelling case that global phenomena such as poverty, the medical brain drain, organ tourism, and climate change ought to inform the health policy we craft for newcomers and natives alike.

1

Health and Migration

A Combustible Mix

In 2006 Johnson Aziga, an immigrant from Uganda, became the first person in Canada to be convicted of murder because he had infected his sexual partner with HIV.1 Aziga’s conviction followed the 2003 conviction in Great Britain of Mohammed Dica, a Somali asylum seeker, who became the first person convicted in Britain for recklessly transmitting HIV.2

On September 9, 2009, in Washington, DC, a Republican congressman from South Carolina, Joe Wilson, shattered decorum by shouting “You lie!” to President Barack Obama as Obama promised Congress that his health care reform bill would not provide any health care to undocumented immigrants.3

In October 2015, Poland’s right-wing Law and Justice Party came out on top in parliamentary elections after its leader, former prime minister Jarosław Kaczyński, warned that migrants entering Europe could bring “diseases that are highly dangerous and have not been seen in Europe for a long time: cholera on the Greek islands, dysentery in Vienna.” He added, “there are some differences related to geography, various parasites, protozoa that are common and are not dangerous in the bodies of these people, [but] may be dangerous here. Which doesn’t mean there is need to discriminate anyone [sic], but you need to check.”4 As Kaczyński spoke, thousands of migrants from the Middle East languished in detention camps in Hungary and other parts of Europe. According to reports by Human Rights Watch, detainees experienced “heart attacks, insulin shock or seizures” and newborns had suffered from “serious fevers and vomiting” without receiving any medical assistance.5

These very different incidents, from different corners of the globe, illustrate the pain, passion, and complexity that arise when immigration and health policy collide. On their own, both immigration and health are increasingly salient and ever more contentious. Questions of health policy—what care to offer, to whom, and how to reduce its cost, as well as how to prevent the spread of both communicable and noncommunicable diseases—have a unique and personal impact on people’s lives. They influence how long we live as well as the quality of our lives. They touch upon our deepest cultural, religious and moral beliefs, as debates about reproductive and sexual health, and the “right to die” attest. They also have an enormous impact on the economy of persons, nations, and the globe. Individuals, families, and governments can and do go bankrupt trying to pay for health care, and in the absence of a healthy population, the prospect of economic progress is dim.

Politics and rhetoric also run hot when it comes to immigration. As globalization, war, civic unrest, and economic deprivation have led to steep increases in migration to the West from the Middle East and less developed regions of the world, many residents of wealthy countries have worried about migration’s impact on their own security, jobs, communities, culture, and very way of life. Terrorist attacks in Paris and California in the autumn of 2015 only added to these concerns, fueling fierce anti-immigrant sentiment in many parts of the West. Even in Germany, the European nation that has been most welcoming to the recent wave of migrants, the anti-immigrant Pegida group organized ten thousand people to march in Dresden in autumn 2015.6 Earlier that summer, Hungary closed its borders to Middle Eastern refugees. In the United States, thirty-one governors claimed that they would not accept Syrian refugees in their states,7 and Donald Trump, then the front-runner for the Republican Party’s nomination for the presidency, called for banning the entry of Muslims into the United States.8

Complex and contentious in their own right, questions about health and immigration often provoke even more intense reactions when they intersect. In a time of economic insecurity, nations understandably wonder what health benefits they can afford to offer, and whether noncitizens, or at least those who lack legal residency, are deserving of the benefits provided. Likewise, in an era in which both health officials and the media repeatedly warn of the next global pandemic, residents of highly developed nations worry that immigrants from less developed countries will transmit fearsome germs, a concern clearly on display during the Ebola outbreak of 2014. In such an atmosphere, reasoned analysis and effective policy can be hard to find.

In this book we offer that analysis and provide principles for developing policy that is both effective and ethically sound. Looking beyond the overblown rhetoric and partisanship to review the nexus of health and immigration, we show that the relationship between the two is deeper and far more complex than is acknowledged, and that many laws and policies are often counterproductive and unethical, reflecting widely shared misperceptions about immigrants’ health and the burdens they impose on their new homelands.

In the chapters that follow, we explore many widely held misperceptions about the relationship between immigration and health. In this chapter we note four misperceptions that have been especially influential. The first is that migration and migrants pose a unique and significant threat to public health. To be sure, throughout history infectious diseases such as bubonic plague, influenza, and smallpox have followed travelers across the globe. Such epidemics, however, were more likely to follow the movement of armies, commerce, or even casual travel than migration. Indeed, with rare exceptions, newcomers—a term we use to refer to all nonnative residents, regardless of their citizenship or immigration status—are generally healthier than natives. With some exceptions that we will discuss in chapter 2, they are no more likely today to spread novel and fearsome diseases than others who cross borders, or those who live within them. Still, media reports in developed nations continue to stress the supposed high risks of disease-bearing immigrants with headlines such as “‘Potential for a Public Health Disaster’: Illegal Immigrant Surge Leaves Officials With ‘No Idea’ Which Diseases Are Coming Across.”9 Reflecting such fears, nations across the globe screen immigrants for a range of diseases and bar entry to those who are thought to pose a health risk. Such exclusions, we demonstrate, misuse public health resources, offering a false illusion of safety instead of effective infectious disease control. Such policies also reinforce the false perception that immigrants are the source of disease.

A second misperception is that newcomers are sicker than natives due primarily to their own irresponsible ways. This was evident in warnings by Alabama congressman Mo Brooks about the role of “illegal aliens” in a recent measles outbreak in the United States. Representative Brooks reportedly stated:

I don’t think there is any health care professional who has examined the facts who could honestly say that Americans have not died because the diseases brought into America by illegal aliens who are not properly health care screened, as lawful immigrants are. . . . [U]nfortunately our kids just aren’t prepared for a lot of the diseases that come in and are borne by illegal aliens.10

Reflecting such sentiment, public authorities often target newcomers such as Johnson Aziga and Mohammed Dica for highly coercive and punitive public health controls on the assumption that they pose a unique public health threat. The refusal by many states to provide state-supported health care to immigrants has likewise been justified on the claim that the health care needs of immigrants result from their own unhealthy ways. In reality, for the most part, newcomers are healthier and use fewer health care resources than natives. Although their lesser use of health services may be due in part to policies that make it hard for them to obtain health care, there simply is no evidence supporting the widespread belief that newcomers are more likely than natives to engage in unhealthy lifestyles. To the contrary, for many newcomers, the risk to health arises not from adhering to their traditional culture but from assimilating. The longer newcomers reside in their new countries, the more their health patterns begin to converge with that of natives.

A third false perception is that newcomers engage widely in what is sometimes called “health tourism,” migrating precisely in order to take advantage of Western health care systems. Although as we shall discuss in chapter 8, there is a robust global market in medical tourism, most of that travel is from wealthy countries to less developed nations. In other words, natives of highly developed countries tend to go to poorer nations for (usually cheaper) health care. The flow does not go the other way. Migrants do not come, in any significant numbers, to wealthy countries for health care. They do, however, move to wealthier countries to provide health care services, creating a brain drain in poor countries, as their most educated health professionals emigrate for better employment opportunities.

The final fiction is that medical services for immigrants place an inordinate strain on taxpayers. In a 2004 survey, more than 60 percent of Americans agreed that taxpayers have to pay too much to support services such as education and health care for undocumented immigrants,11 and a 2013 survey found that over 40 percent of the US population believed that immigrants (both documented and undocumented) placed a burden on the country.12 More than 60 percent of Australians hold a similar belief, as do majorities in many European Union countries.13 In reality, although the provision of services to immigrants can at times strain the budgets of local communities with large numbers of refugees or undocumented immigrants, as occurred in parts of Europe during the migration crisis of 2015, immigration as a whole provides economic benefits to receiving countries.14 Moreover, as noted earlier, immigrants as a group use fewer health care resources than do natives. Indeed, newcomers often pay taxes to support health care services they are barred from receiving. Thus they subsidize the health care of people far wealthier than they are.

In the chapters that follow we explore the impact of these misperceptions and analyze the laws, policies, and norms that lie at the juncture between immigration and health. Throughout, our focus remains on the nexus of migration and health. We do not, except where necessary to examine health policies relating to immigration, address other contentious issues related to immigration, such as whether nations should be more or less open to refugees, or create a path to citizenship for undocumented newcomers. We also do not consider what type of health care system would best serve any nation. Rather, we ask, how should immigration and health policies intersect? How should nations respond to the health of newcomers?

We begin in this chapter by looking more closely at migration and migrants in the twenty-first century. This examination reveals that immigration is more varied and nuanced than is commonly appreciated. We then consider the relationship among health, individuals, nations, and the global community, looking first at how fear about immigrants spreading disease has influenced immigration law, sanctioning health and disability-based discrimination that would be viewed as deeply troubling in other contexts. We next consider how domestic public health policies and hence public health are adversely affected by the punitive policies that result from the misperceptions of the health risks posed by immigrants. We then turn to a discussion of access to health care and demonstrate that nations throughout the globe erect a multitude of barriers to newcomers’ access to care. In effect, once immigration is considered, it becomes clear that no nation’s health care system is truly universal. Newcomers, or at least some classes of them, are often excluded from their receiving nation’s health care system. This exclusion, based largely on false beliefs, hampers efforts to create high-quality, cost-effective health care systems.

We then more fully explore the global dimensions of health, explaining why many current policies are unethical as well as ineffective. We begin by noting the obvious: health is an essential human good. Every developed country attempts to protect the health of its population, and all regulate both the provision of health care, as well as industries and practices that can threaten health (such as the sale of tobacco). In addition, all developed countries spend a large portion of their budgets on financing health care for many of their residents. In effect, the nations of the world act as if health were a public, rather than a private, matter.

Still, we tend to think of nations’ obligations for health in national terms, as if a nation’s duties were limited to its own citizens, or perhaps its own legal residents. This is not to say that nations don’t target health in their foreign aid policies, but such aid is viewed as supererogatory. This widely shared assumption overlooks the fact that both the benefits and threats to health cannot be confined to any one nation’s citizens or legal residents. Rather, an individual’s health, we will show, is determined at a far broader population level, influenced by a host of factors, often called the social determinants of health. These social and environmental factors influence the health of both citizens and newcomers, as well as populations across the globe, creating an interdependency of health that transcends both immigration status and national boundaries. Indeed, as we will urge, health is a global public good, meaning that its consumption by one does not diminish the health of another, nor can its benefits be confined to an individual or group. As our discussion of medical tourism and the medical brain drain will show, the flow of health care needs and services is more complex and multidirectional than is acknowledged. The homelands of newcomers often provide significant health benefits to those in receiving countries. Sending countries also bear many of the health consequences of policies that emerge from wealthier countries. The medical brain drain is a good example. When it comes to health, the costs and benefits, duties and obligations, are widely dispersed around the globe.

These characteristics of health, we explain, are not simply descriptive. They have important normative implications. The global public good dimensions of health create duties with respect to health. While some of these duties may extend to all persons, regardless of residency, other factors that have moral weight, including proximity, solidarity, cost, and even the depth of interdependency among all people mean that policies that discriminate against newcomers in either the provision of care or the enforcement of public health policies are especially problematic. None of the oft-cited arguments for the disparate treatment of newcomers with respect to health can survive careful analysis. Or to put it another way, when it comes to he...