Society for Medical Anthropology

A section of the American Anthropological Association

CURRENT TOPIC

 

“Unauthorized Im/migration and Health”

Prepared for the annual meeting of the Critical Anthropology of Global Health (CAGH) Interest Group 2008 AAA Annual Meetings San Francisco, CA November 22, 2008

Drafted by:

  • Sarah Willen, PhD, MPH (Departments of Anthropology and Social Medicine & Global Health, Harvard University – sarah_willen@hms.harvard.edu)
  • Heide Castañeda, PhD, MPH (Department of Anthropology, University of South Florida – hcastane@cas.usf.edu)

Objectives

The aim of this “Take a Stand” initiative is to stimulate empirically grounded, critical dialogue about a burgeoning yet insufficiently addressed global health challenge: unauthorized (i.e., “undocumented” or “illegal”) migrants’ and immigrants’ need for – and generalized lack of access to – needed health care services both in the United States and elsewhere around the globe.

The goal of this brief are (1) to introduce members of CAGH and other interested medical anthropologists to the complex matter of unauthorized im/migration and health; (2) to provide a preliminary, working bibliography on the topic; and (3) to provide a preliminary list of issues that merit further research, deliberation, and analysis. As additional scholars and scholaractivists join the conversation, we expect that this list – and this Take a Stand initiative itself – will evolve organically.

Overall, we contend that critical medical anthropologists should play an active role in:

  • Gathering and analyzing both case-specific and comparative data concerning matters of unauthorized im/migration and health;
  • Identifying key practical and ethical challenges and dilemmas that demand ethnographic attention;
  • Elucidating the potential policy relevance of our work;
  • Making our findings and recommendations visible and accessible to anthropologists and non-anthropologists alike; and
  • Participating in – and initiating – multi-stakeholder conversations about (a) why the issue of unauthorized im/migration and health is a critical national, as well as global, health concern, and (b) how to conceptualize and address its practical, ethical, and theoretical dimensions.

These forms of attention and involvement are crucial if medical anthropologists hope to play an active role in shaping how politicians, policymakers, public health officials, activists, unauthorized migrants, and other key stakeholders think about and respond to this politically charged issue. For instance, the matter of unauthorized im/migration and health raises 2 fundamental questions about citizenship, social contracts, human rights, health disparities, equity, and community welfare.

Given the impending change in political administration within the United States, we believe this is an especially opportune time to begin thinking about the contributions that critical medical anthropologists are well-positioned to make. Our near-term goals include:

  • Preparing a publicly accessible, modifiable working bibliography on immigration and health and posting it on the SMA/CAGH website
  • Creating a Working Group on Unauthorized Im/migration and Health within CAGH
  • Creating an electronic listserve to facilitate conversation among working group members

Subsequent steps (i.e., issue-specific task forces, coordination of panels or conferences, publications, etc.) will be determined as the dialogue evolves.

Premises

Our basic premises are as follows:

  1. The individual, clinical, institutional, and governmental health challenges associated with unauthorized transnational im/migration are among the most complicated – and least studied – health challenges stemming from contemporary processes of globalization.
  2. Challenges associated with unauthorized migration and health are currently addressed in substantially different ways within different “receiving” countries and, moreover, within different cities/districts/regions of the same country.
  3. In many countries, government inattention has led non-government organizations (NGOs) to take primary responsibility for unauthorized migrants’ health needs. Localized NGOs, however, cannot provide comprehensive solutions to systemic challenges.
  4. A growing body of medical anthropological scholarship on these issues now exists, but no mechanism is currently in place to facilitate communication among scholars who share these interests.
  5. Cross-disciplinary dialogue on unauthorized migration and health is urgently needed among researchers in medical anthropology, public health, public policy, clinical medicine, nursing, health administration, and law. A final assumption concerning our partner discipline, public health, merits mention as well:
  6. Issues of unauthorized migration and health have not yet been adequately addressed by three of the major approaches within contemporary public health theory: “health and human rights,” “health inequalities / health disparities,” and “public health ethics." (Willen 2006)

Background

One of the most significant consequences of contemporary globalization is the process by which an estimated 191 million people had left poorer regions of the world for richer ones in search of economic opportunity by 2005, about 50 percent of them women**. While precise numbers are difficult to establish, a large proportion of these migrants – 30-40 million, according to International Organization for Migration (IOM) estimates** – leave their homes in “developing” or “Third World” countries and travel to “First World” countries on an “unauthorized,” “undocumented,” or “illegal” basis. Four global trends, in particular, shape contemporary migration processes: global political and economic inequalities, political conflict and war, anti-immigration pressures in “receiving” countries, and high demand for unauthorized im/migrants’ cheap, exploitable labor.

Despite the great diversity among unauthorized im/migrants, nearly all share two common characteristics: they have health needs, and they are excluded, in part or in full, from the systems of health care promotion, protection, and provision via which local citizens’ needs are addressed. In many receiving countries, human rights and migrant advocacy organizations and, to a certain extent, academics have been calling for increased attention to unauthorized im/migrants’ health needs. Their arguments, however, have largely failed to persuade mainstream actors – i.e., politicians, policymakers, and the broader public – to pay systematic attention to, or to take responsibility for, those needs. There are at least two reasons for this lack of success: first, health care systems – whether publicly financed or privately run – are already strained and overburdened, and second, because illegal migrants are construed as falling outside the bounds of prevailing social contracts linking states and their constituent citizens.

Some have argued that unauthorized migrants’ exclusion from local health care systems “makes sense.” According to this line of reasoning, national systems of health care provision are part of broader social contracts linking citizens to the broader political community, and “unauthorized,” “undocumented,” “clandestine,” “irregular,” or “illegal” im/migrants are not part of that social contract (or the citizenship-based arrangements that govern private insurance arrangements). As non-members, proponents of this stance would contend, neither host states nor host societies are under any obligation – legal, moral, or otherwise – to care for unauthorized migrants’ health-related needs.

Within most countries hosting substantial unauthorized im/migrant populations, the hardline version of this position – that unauthorized migrants possess no health-related rights or entitlements whatsoever – has been deemed untenable. Yet virtually no host countries have accepted its opposite – i.e., that unauthorized migrants are entitled to exactly the same forms of health care or the same health benefits as citizens. Caught between the extreme options of full exclusion and full inclusion, most host countries in North America, Europe, and other world regions are currently struggling to determine how best to respond to the health-related needs of unauthorized migrants and, for that matter, to the health needs of other non-citizen populations including refugees, asylum seekers, and victims of human trafficking.

In other words, even as high profile economic sectors in some countries (for instance, construction and agriculture) rely heavily upon the unprotected labors of unauthorized migrants, politicians and policymakers have often neglected, or even deliberately ignored, the healthrelated challenges associated with unauthorized migration. When attention has been paid to these issues, it has not always resulted in improved accessibility, affordability, or adequacy of care.

**International Organization for Migration. 2008. Global Estimates and Trends. Accessed on November
14, 2008, at http://www.iom.int/jahia/Jahia/about-migration/facts-and-figures/global-estimates-andtrends.

Questions and dilemmas

The conjunction between unauthorized migrants’ pressing health needs, on one hand, and their widespread lack of health care options, on the other, raises a wide array of unresolved questions and dilemmas in the domains of politics, public policy, health economics, and ethics, including:

  • Is there a universal “right to health” that applies to unauthorized im/migrants?
  • Are unauthorized migrants entitled to health care within host societies?
  • If so, on what legal, political, economic, moral and/or ethical grounds do they possess this right/these entitlements?
  • If so, to what forms of care are unauthorized migrants entitled (i.e., comprehensive health care? a basic or limited basket of services?)?
  • If so, who is responsible for providing unauthorized migrants with health care services?
  • If so, who is responsible for paying for these services, and how should payment be coordinated?
  • How are unauthorized im/migrants (men, women, children) actually attending to their health care needs? Which providers/health care institutions are they consulting, how do they learn about and interact with these providers, and to what extent do these arrangements meet im/migrants’ needs?
  • What fears do unauthorized migrants harbor upon accessing/attempting to access health care? Are these fears substantiated?
  • What are the personal and public health ramifications of delays in care-seeking among unauthorized migrants?
  • Who is lobbying for or against migrants’ health rights? What are these actors’ or organizations’ arguments, agendas, objectives, audiences, and coalition partners?
  • How do answers to these questions vary across “receiving” countries?

These are urgent questions, and they are also thorny questions lacking in clear-cut answers. Indeed, there exists no real framework – either at a national or a global level – for thinking through these questions in any organized or coherent manner. Instead, despite the global scope of this major contemporary health challenge, stakeholders at all levels, including those in positions of power as well as civil society actors with activist or reformist agendas, continue to rely more on impressionistic or improvisational strategies than they engage in organized deliberations with colleagues in their own and related sectors.

Issues for further discussion/research

  • Comparative investigation of unauthorized migrants’ ability to access health care in different “receiving” countries (in general or in specific areas like emergency care, reproductive health care, mental health care, preventative medicine, children’s health, etc.)
  • The deportation of uninsured migrants by health care institutions and/or government authorities
  • Access to expensive but lifesaving care (major surgeries, transplants, etc.)
  • Clinical ethics and practical decision-making by health care workers and administrators
  • Medical and humanitarian implications of increased border control and law enforcement
  • Unauthorized im/migration and reproductive politics
  • The interface among medicine, the law, and state institutions
  • The role of health NGOs in addressing im/migrant health needs
  • Occupational health hazards (especially in agriculture, meatpacking, etc.)
  • Immigrant advocacy in the health domain
  • The health effects of uncertain legal status
  • Vilification of unauthorized im/migrants as a cause of both public health problems (e.g.,
    infectious diseases, drugs, violence, etc), and rising health care costs
  • Public health threats generated by the denial of health care to unauthorized im/migrants
    and other uninsured/underinsured groups

Preliminary Working Bibliography (to be augmented)

Adout, Rami

  • 2007 Trafficked Women and Political Asylum Seekers. In Transnational Migration to Israel in Global Comparative Context. S.S. Willen, ed. Lanham, MD: Lexington Books.

Berk, Marc L., et al.

  • 2000 Health Care Use Among Undocumented Latino Immigrants: Is Free Health Care the Main Reason Why Latinos Come to the United States? A Unique Look at the Facts. Health Affairs 19(4):51-64.

Braun, T, and W Würflinger

  • 2001 Access to Medical Care for Undocumented Migrants in Germany. Berlin: PICUM.

Castañeda, Heide

  • 2007 Citizenship, Rights, and Ambiguity: Undocumented Migrant Workers and Access to Health Services in Berlin, Germany and Tel Aviv, Israel. In Transnational Migration to Israel in Global Comparative Context. S.S. Willen, ed. Lanham, MD: Lexington Books.
  • 2008a Paternity for Sale: Anxieties over "Demographic Theft" and Undocumented Migrant Reproduction in Germany. Medical Anthropology Quarterly 22(4):340-359.
  • 2008b Undocumented Migration, Health Care and Public Policy in Germany. Anthropology News (May 2008).

Chavez, Leo R.

  • 2003 Immigration and Medical Anthropology. In American Arrivals: Anthropology Engages the New Immigration. N. Foner, ed. Santa Fe: School of American Research Press.
  • 2004 A Glass Half Empty: Latina Reproduction and Public Discourse. Human Organization 63(2):173-188.

Chavez, Leo R., Wayne A. Cornelius, and O.W. Jones

  • 1985 Mexican Immigrants and the Utilization of Health Services: The Case of San Diego. Social Science & Medicine 20:93-102.
  • 1986 Utilization of Health Services by Mexican Immigrant Women in San Diego. Women and Health 11:3-20.

Chavez, Leo R., Estevan T. Flores, and Marta Lopez-Garza

  • 1992 Undocumented Latin American Immigrants and U.S. Health Services: An Approach to a Political Economy of Utilization. Medical Anthropology Quarterly 6(1):6-26.

Chavez, Leo R., et al.

  • 1995 Structure and Meaning in Models of Breast and Cervical Cancer Risk Factors: A Comparison of Perceptions among Latinas, Anglo Women, and Physicians. Medical Anthropology Quarterly 9(1):40-74.
  • 1997 Undocumented Latina Immigrants in Orange County, California: A Comparative Analysis. International Migration Review 31(1):88-107.
  • 2001 Beliefs Matter: Cultural Beliefs and the Use of Cervical Cancer-Screening Tests. American Anthropologist 103(4):1114-1129.
  • 2008. The Latino Threat: Constructing Immigrants, Citizens, and the Nation. Stanford: Stanford University Press. (see especially Chapters 3 & 4)

Fassin, Didier

  • 2004 Social Illegitimacy as a Foundation of Health Inequality: How the Political Treatment of Immigrants Illuminates a French Paradox. In Unhealthy Health Policy: A Critical Anthropological Examination. A. Castro and M. Singer, eds. Walnut Creek, CA: Altamira Press.
  • 2005 Compassion and Repression: The Moral Economy of Immigrant Policies in France. Cultural Anthropology 20(3):362-387.

Fassin, Didier, and Estelle D'Halluin

  • 2005 The Truth from the Body: Medical Certificates as Ultimate Evidence for Asylum Seekers. American Anthropologist 107(4):597-608.
  • 2007 Critical Evidence: The Politics of Trauma in French Asylum Policies. Ethos 3:300-329.

Filc, Dani, and Nadav Davidovitch

  • 2005 Health Care as a National Right? The Development of Health Care Services for Migrant Workers in Israel. Social Theory and Health 15:1-14.
  • 2007 Rights, Citizenship and the National State: Migrant Worker Health Policies in Comparative Perspective. In Transnational Migration to Israel in Global Comparative Perspective. S.S. Willen, ed. Lanham, MD: Lexington Books.

Gruskin, Sofia, et al., eds.

  • 2005 Perspectives on Health and Human Rights. New York: Routledge. Heyman, Josiah McC, Guillermina Gina Núñez-Mchiri, and Victor Talavera
  • 2009 Healthcare Access and Barriers for Unauthorized Immigrants in El Paso County, Texas. Family and Community health 32(1):4-21.

Hirsch, Jennifer S.

  • 2003a A Courtship After Marriage: Sexuality and Love in Mexican Transnational Families. Berkeley: University of California Press.
  • 2003b Anthropologists, Migrants, and Health Research: Confronting Cultural Appropriateness. In American Arrivals: Anthropology Engages the New Immigration. N. Foner, ed. Santa Fe: School of American Research Press.

Ho, Ming-Jung

  • 2003 Migratory Journeys and Tuberculosis Risk. Medical Anthropology Quarterly 17(4):442- 458.

Holmes, Seth

  • 2006 An Ethnographic Study of the Social Context of Migrant Health in the United States. PLoS Med 3(10):e448.
  • 2007 “Oaxacans Like to Work Bent Over”: The Naturalization of Social Suffering among Berry Farm Workers. International Migration 45(3): 39-68.

Horton, Sarah

  • 2004 Different Subjects: The Health Care System's Participation in the Differential Construction of the Cultural Citizenship of Cuban Refugees and Mexican Immigrants. Medical Anthropology Quarterly 18(4):472-489.

Kanaiaupuni, Shawn Malia

  • 2000 Child Well-Being and the Intergenerational Effects of Undocumented Immigrant Status. Institute for Research on Poverty Discussion Paper No. 1210- 00.

Kerner, Caroline, et al.

  • 2001 "Thank God She's Not Sick": Health and Disciplinary Practice among Salvadoran Women in Northern New Jersey. In Geographies of Women's Health International Studies of Women and Place. I. Dyck, N.D. Lewis, and S. McLafferty, eds: Routledge.

Kullgren, Jeffrey T.

  • 2003 Restrictions on Undocumented Immigrants' Access to Health Services: The Public Health Implications of Welfare Reform. American Journal of Public Health. Mann, Jonathan M.
  • 1999 Health and Human Rights: A Reader. New York: Routledge. Marks, Stephen P.
  • 2003 Health from a Human Rights Perspective. Pp. Working Paper: Francis Xavier Bagnoud Center for Health and Human Rights.

McGuire, Sharon, and Jane Georges

  • 2003 Undocumentedness and Liminality as Health Variables. Advances in Nursing Science 26(3):185–195.

McNeill, Paul M.

  • 2003 Public Health Ethics: Asylum Seekers and the Case for Political Action. Bioethics 17(5-6):487-502.

Menjívar, Cecilia

  • 2002 The Ties that Heal: Guatemalan Immigrant Women’s Networks and Medical Treatment. International Migration Review 36(2):437-466.

Nachman, Steven R.

  • 1993 Wasted Lives: Tuberculosis and Other Health Risks of Being Haitian in a U.S. Detention Camp. Medical Anthropology Quarterly 7(3):227-259.

Nijhawan, Michael

  • 2005 Deportability, Medicine, and the Law. Anthropology & Medicine 12(3):271-285.

PICUM, ed.

  • 2002 Book of Solidarity - Volume 1: Providing Assistance to Undocumented Migrants in Belgium, Germany, the Netherlands, and the UK. Antwerp: De Wrikker.
  • 2003 Book of Solidarity - Volume 2: Providing Assistance to Undocumented Migrants in France, Spain and Italy. Antwerp: De Wrikker.

Romero-Ortuño, Roman

  • 2004 Access to Health Care for Illegal Immigrants in the EU: Should We Be Concerned? European Journal of Health Law 11(3):245-272.

Rosenthal, Anat

  • 2007 "Illegality" and Illness in the Everyday Struggles of Undocumented HIV+ Migrant Workers in Tel Aviv. International Migration 45(3):134-156.

Ruger, Jennifer Prah

  • 2006 Toward a Theory of the Right to Health: Capability and Incompletely Theorized Agreements. Yale Journal of Law and the Humanities 18:273-326.

Sargent, Carolyn F.

  • 2006a Lamenting the "Winter" of French Fertility: Politics, Power, and Reproduction among Malian Migrants in Paris. Curare 29:71-80.
  • 2006b Reproductive Strategies and Islamic Discourse: Malian Migrants Negotiate Everyday Life in Paris, France. Medical Anthropology Quarterly 20(1):31-49.

Sargent, Carolyn, and Dennis Cordell

  • 2003. Polygamy, Disrupted Reproduction, and the State: Malian Migrants in Paris, France. Social Science & Medicine 56:1961-72.

Scott, Penelope

  • 2004 Undocumented Migrants in Germany and Britain: The Human "Rights" and "Wrongs" Regarding Access to Health Care. Electronic Journal of Sociology.

Siddharthan, Kris, and Melissa Ahern

  • 1996 Inpatient Utilization by Undocumented Immigrants Without Insurance. Journal of Health Care for the Poor and Underserved.

Siddharthan, Kris, and Sudha Alalasundaram

  • 1993 Undocumented Aliens and Uncompensated Care: Whose Responsibility? American Journal of Public Health 83(3):410-412.

Taran, Patrick A.

  • 2000 Human Rights of Migrants: Challenging of the New Decade. International Migration 38(6):7-46.

Ticktin, Miriam

  • 2006 Where Ethics and Politics Meet: The Violence of Humanitarianism in France. American Ethnologist 33(1):33-49.

Toebes, B.C.A

  • 1999 The Right to Health as a Human Right in International Law. Antwerp; Oxford: Intersentia.

Torres, Alberto M., and Belen Sanz

  • 2000 Health Care Provision for Illegal Immigrants: Should Public Health be Concerned? Journal of Epidemiology and Community Health 54:478-479.

Wailoo, Keith, Julie Livingston, and Peter Guarnaccia, eds.

  • 2006 A death retold : Jesica Santillan, the bungled transplant, and paradoxes of medical citizenship. Chapel Hill: University of North Carolina Press.

Walter, N., Bourgois, P., Loinaz, H.M.

  • 2002 Social Context of Work Injury among Undocumented Day Laborers in San Francisco. J Gen Intern Med 17(3):221-229.

Willen, Sarah S.

  • 2005 Birthing "Invisible" Children: State Power, NGO Activism, and Reproductive Health among Undocumented Migrant Workers in Tel Aviv, Israel. Journal of Middle East Women's Studies 1(2):55-88.
  • 2006 "Illegal" Migration as a New Global Health Challenge: Israeli Perspectives and European Comparisons. MPH thesis. Department of Global Health, Rollins School of Public Health, Emory University. Atlanta, GA.
  • 2007 Seeing the "Holy Land" with New Eyes: Undocumented Labor Migration, Reproductive Health, and the Fluctuating Borders of the Israeli National Body. In Reapproaching Borders: New Perspectives on the Study of Israel-Palestine. S. Sufian and M. LeVine, eds. Lanham, MD: Rowman & Littlefield.
  • n.d. “Do ‘Illegal’ Migrants Have a Right to Health? Engaging Ethical Theory as Social Practice at a Tel Aviv Open Clinic.”

 

Selected newspaper articles

Websites