Natives and Newcomers

Using the 2015 Ebola epidemic and the global migrant crisis as examples, this chapter suggests that following a period of norm change, there is reason to be optimistic about the potential for solidarity between newcomers and natives for the sake of health. In health our shared humanity and vulnerability are evident. The Ebola epidemic in 2014 illustrates both how a slow global response to the disease resulted in the deaths of over 11,000 people and how a willingness on the part of nations and individuals to act in solidarity with the victims of Ebola brought an end to the epidemic. Responses to the recent global migration crisis, including a mix of public and private sponsorship of refugees in Canada, are also examined in this chapter. This chapter suggests policy recommendations to ensure that newcomers have their health needs met and indicates that equal access to health care for newcomers and natives is critical and will be facilitated by cultural competency and nonexclusionary health policy.

Health as a Global Public Good

Contrary to the standard view that health is a private good, health should be viewed as a public good: its benefits are nonexcludable and nonrivalrous. Health should, in fact, be understood as a global public good, in light of globalization. Chapter 6 illustrates this analysis with reference to the global eradication of smallpox. Understanding health as a global public good, rather than as a private good, has implications for a nation’s moral obligations to newcomers and the health policy that its government crafts: one person’s health can adversely affect another’s health, and good health can benefit many. Given the public good dimensions of health, failure to help newcomers in need of care may not only be counterproductive because it puts the health of all at risk, it may also violate basic principles of fairness, reciprocity and justice.

Denying the Right to Health

Many nations claim to respect the right to health, which requires states to provide access to necessary health care without discrimination of any kind. Nevertheless, most states that purport to recognize the right to health discriminate against some classes of newcomers, especially unauthorized immigrants. This chapter reviews the status of immigrants’ right to health under international law and then turns to an examination of immigrants’ access to health insurance in Canada and the European Union. The chapter demonstrates that even in nations that are widely believed to have universal health care systems, many classes of immigrants are left without access to the means to pay for needed health care. As in the United States, these exclusions impact the health of newcomers and natives alike.

A Nation of Uninsured Immigrants

The United States is unique among developed countries in not providing health insurance to all of its citizens. But newcomers, both legal and undocumented, are far more likely to be uninsured than natives. This chapter reviews US law, including the Affordable Care Act, regarding immigrants’ access to health insurance, exposing the conflicting and inconsistent policies towards including immigrants within the nation’s health care system. These policies not only reduce immigrants’ access to health care, they add significant complexity to the US health care system, and create a range of health and economic costs to immigrants and natives alike. The chapter focuses in particular on the practice of medical repatriation, whereby hospitals send seriously ill immigrants to their countries of origin, explaining how the conflicting edicts of US health law encourage the practice by requiring hospitals to treat all emergency patients regardless of citizenship or insurance status, while denying many immigrants public benefits for nonemergency care.

Health and Migration

Health and migration are each highly contentious issues. Four widely held myths have been especially influential in shaping policy at the intersection between immigration and health: newcomers pose a unique and significant threat to public health; they are sicker than natives due to their own irresponsible ways; newcomers often immigrate to take advantage of Western health care systems; and newcomers place a significant strain on taxpayers. This chapter shows that each of these myths is false. The chapter also reviews the diversity of refugees and other migrants around the globe, as well as the health status of the migrants, noting that, as a group, migrants tend to be healthier than natives, a phenomenon known as the healthy immigrant effect. The chapter ends with a discussion of the distinction between law and ethics.

Strangers for the Sake of Health

Global health affords an opportunity for people from diverse countries to interact and to develop trusting ties with one another. People from affluent nations initiate many of these health interactions, and although unintentionally, often do so at the detriment of people in poor countries. This chapter develops this argument with reference to medical brain drain, medical tourism and international transplantation. Basic principles of fairness, reciprocity, and justice suggest that a global scenario in which the health of the global poor is sacrificed for people in affluent countries is morally unsettling. A more inclusive approach to the health of newcomers would be an important step toward health justice.

Creating Global Health

When the global social determinants of health are taken into account, it can be argued that affluent nations have responsibility for the health of newcomers. Affluent nations have played a role in shaping the health of the global poor, many of whom migrate to escape the conditions that are created by the global social determinants of health and that adversely impact their health. Although there are many ways that affluent countries can affect the health of people in poor countries, this chapter focuses on the implications of poverty for health, and how affluent countries have contributed to global poverty, as illustrated with two examples: international tax law and tax injustice, and environmental harms, including climate change. Given the pivotal role of affluent nations in the global social determinants of health, these nations have violated a negative duty not to harm others and therefore have a moral responsibility to compensate for that harm.

Blaming the Victim

International law recognizes public health protection as a human right that states are obligated to protect. Government efforts to fulfill that right may at times justify the restriction of individual liberty, but because of the perceived association between disease and immigration, highly coercive public health measures such as isolation and quarantine have often been applied disproportionately against immigrants. This chapter reviews the history and constitutional status of the use of coercive public health measures and the constitutional rights of newcomers in the United States, then considers the case of tuberculosis (TB), which tends to be far more prevalent in immigrant communities than in native populations in the developed world. Despite the higher prevalence of TB in among newcomers, highly coercive and punitive approaches to communicable disease control are unlikely to prevent the disease’s spread. Communicable diseases such as TB demonstrate the interdependency of human health and the importance of meeting the needs of people in high-prevalence countries as well as providing health care for, and working with rather than against, immigrants in their new homes.

Keep Out!

Humans have long blamed immigrants and outsiders for epidemics. This perceived association between newcomers and disease has led many nations to impose health-related immigration controls that screen newcomers for disease and disability and deny entry to many newcomers on health and disability-related grounds. In the United States, quarantine and other such policies began in the nineteenth century, and were long influenced by both racism and eugenics; more recently, many nations around the globe have imposed travel bans, barring entry by people who are HIV positive. Nations also perpetuate disability discrimination, excluding immigrants with a range of disabilities on the theory that they will be unproductive and costly to taxpayers. These health- and disability-related immigration exclusions fail to protect public health and reinforce stigma and discrimination against immigrants and natives with disabilities.

Introduction

The 2015 Ebola epidemic, as well as the global migration crisis, bring to light the connection many people make between loathsome disease and strangers. Myths about newcomers and disease have long informed both immigration policy and health policy. This book focuses on the latter and reviews basic demographics about migrants and their health, dispelling the myths that have thus far informed health policy. The book argues that health should be understood as a global public good and that understanding it as such has important moral and practical implications that ought to be taken into account as health policy is developed. This introduction provides a chapter-by-chapter outline of the book.