Scaring Undocumented Immigrants Is Detrimental to Public Health

As a rule, immigrants tend to be healthier than US-born persons on arrival to the United States; thus, they may require and use fewer public health services in the initial years after immigration and are less likely than US-born persons to visit emergency departments.¹ Immigrants have a higher life expectancy than their US-born counterparts and lower mortality attributable to major cancers, cardiovascular disease, diabetes, respiratory illnesses, suicide, and unintentional injuries. However, this “healthy immigrant” effect erodes over time, and immigrants are less likely to engage in preventive health care. Undocumented persons in particular visit physicians less frequently and use fewer preventive services than do other immigrants and US-born people. As a result, untreated communicable diseases may be transmitted to others, and noncommunicable chronic diseases, which are often easily and inexpensively diagnosed and treated, may impose a heavy financial cost if diagnosed later after complications have developed.

PUBLIC HEALTH IS PUBLIC SAFETY

Since the beginning of the current administration in January 2017, Immigration and Customs Enforcement (ICE) has been given wider latitude to arrest undocumented persons, resulting in an increase in immigration-related arrests, including more than twice as many arrests of “noncriminal” undocumented immigrants in fiscal year 2017 as in 2016. Many police chiefs and sheriffs have decried the targeting of undocumented immigrants in their jurisdictions as negatively affecting public safety by escalating community fear and mistrust of law enforcement. These officials recognize that their ability to solve, prosecute, and prevent crime becomes more difficult when victims and witnesses are afraid to come forward and cooperate with law enforcement.

Public health officials should have similar concerns about the current climate around immigration in the United States and the challenges it presents to protecting public health. Recent news reports of US Customs and Border Patrol (CBP) officers detaining persons seeking health care at Texas hospitals should serve as a wake-up call for the public health community. Although health care facilities are “sensitive places”—areas in which the enforcement activities of ICE and CBP are to be avoided²—CBP officers in Texas identified undocumented individuals at roadblocks and followed them to hospitals, justifying these actions by stating that officers did not detain people at the hospital but simply took them into custody after they left the hospital. In addition to hospitals, “medical treatment and health care facilities,” such as “doctors’ offices, accredited health clinics, and emergent or urgent care facilities” are on this list of safe places.²

Unfortunately, community concerns about government agencies sharing information with ICE have been validated by disclosures that agencies such as the Department of Licensing in Washington State shared lists of potentially undocumented driver’s license applicants with ICE over several months. This occurred despite an executive order signed by the Washington governor restricting the state’s role in enforcing federal immigration policies. Media accounts such as this are likely to increase concerns among immigrants who may be apprehensive about sharing information about themselves, family members, or community members.

PUBLIC HEALTH REQUIRES PUBLIC TRUST

Undocumented immigrants who need health services may be afraid to seek them out, concerned that their information could be shared with other government agencies and lead to arrest or deportation. In several studies, foreign-born persons have reported fear of immigration-related repercussions as a barrier to HIV testing and care or tuberculosis diagnosis.^3,4 Although concerns about HIV testing and care may be related to restrictions against people with HIV entering the United States, which were lifted in 2010, it illustrates the potential for immigration-related fears to result in decreased interaction with public health agencies. The fear of sharing information is likely as formidable and pervasive a barrier as the actual sharing of information. Indeed, in a study conducted after the HIV immigration ban was lifted, Lechuga et al.⁵ reported that Latino immigrants were less likely to report previous HIV testing when they feared that medical personnel would report their information to ICE. Several studies found that in Latino communities, changes in immigration policy or concerns regarding immigration can lead to decreased access to health services of all kinds.⁶

Similarly, contact-tracing and partner services, the practice of interviewing contacts who may have been exposed to communicable disease, are crucial public health strategies for the prevention of diseases such as HIV, sexually transmitted infection, and tuberculosis. Contacts represent a key population for intervention to slow the spread of infections. Moreover, contact-tracing and partner services for one infection may contribute to the prevention of others: sexual contacts may be offered postexposure or preexposure prophylaxis to prevent acquisition of HIV, and persons diagnosed with HIV or tuberculosis can be tested for the other infection to identify those with both infections. However, the success of these key strategies depends on the cooperation of infected persons and their exposed contacts. Similarly, the timely diagnosis of noncommunicable diseases allows for interventions to keep families and communities healthy and productive.

FEAR MAY CONTRIBUTE TO HEALTH DISPARITIES

The current state of immigration enforcement in the United States should be a grave concern for the public health community, given that it may heighten existing health disparities. In 2016, foreign-born individuals accounted for 67.9% of people diagnosed with active tuberculosis in the United States; the incidence of active tuberculosis among foreign-born persons was approximately 14 times that among US-born persons.⁷ To a lesser extent, foreign-born persons are disproportionately affected by HIV and are more likely to have a late diagnosis, indicating difficulty reaching this community with HIV testing. Significant levels of HIV and tuberculosis stigma within many immigrant communities may contribute to reduced levels of screening and decreased likelihood of sharing information about one’s contacts or sexual partners with public health staff. In some cases, homophobia may result in intersectional stigma for men who have sex with men who may be at risk for HIV and sexually transmitted infections. Immigrants and refugees face other barriers to obtaining public health services, including language barriers, hours that may not be conducive to those working multiple jobs or shift work, and cultural attitudes that favor treatment of illness over prevention of disease.

Some may believe that only undocumented immigrants are affected by stricter immigration enforcement, but that is a simplistic view that denies the reality of the millions of immigrants living in the United States. Families may have a mix of documented and undocumented members. The reluctance to call attention to undocumented family or community members may lead to poorer health outcomes in immigrant communities.

Public health advocates must denounce policies that impede efforts to promote public health and are discriminatory and unjust. However, this conversation must reach beyond the public health community. To effect change, we also must share with elected officials the effect of current immigration policies on our ability to protect public health and advocate for policies that do not result in fear deterring people from seeking health services.

Immigrant communities contribute extensively to the US health care workforce: immigrants accounted for 17.1% of the overall workforce in 2015 but accounted for 27.9% of physicians and surgeons and 23.8% of nursing, psychiatric, and home health aides. In 2013, newly arrived immigrants were more likely than US-born persons to hold a bachelor’s degree, contributing to revitalization of communities and supporting local economies. Maintaining immigrant health, in addition to optimizing public health at minimal cost, is essential to preserve an optimal workforce. Scaring undocumented immigrants is detrimental to public health.