Immigrant Health: Anchoring Public Health Practice in a Justice Framework

The nexus between policy actions and immigrant health is central in this issue of AJPH in two articles by Young and Wallace (p. 1171) and Rothstein and Coughlin (p. 1179), serving as a reminder of the need for public health practitioners to adopt a framework that explicitly connects the dimensions of social determinants of health with population health outcomes. Such a framework incorporates a root cause analysis to elucidate the factors contributing to observed health results, including the centrality of economic, social, and environmental conditions.

EFFECTIVE PRACTICES

Young and Wallace show how policies that marginalize and criminalize immigrants can minimize the effect of actions taken to ensure access to health-affirming resources. Their essay provides a critical discussion of the public health implications of states’ complex, contradictory contexts in which immigrants may, for example, simultaneously benefit from public programs while living under the specter of immigration enforcement. Their research points to the need to account for interactions across the broad dimensions that affect both individual and community well-being.

Rothstein and Coughlin note that for a quarantine to succeed, there must be a set of protections in place that minimize the legal, economic, and social effects on vulnerable individuals who need to be quarantined. One strategy for dealing with the unintended consequences of public health actions is to enact as few regulations or practices as possible that restrict individual liberty. Rothstein and Coughlin offer an alternative to this approach in their notion of “safe harbor provisions,” which can complement actions and regulations enacted to protect population health; such provisions make it both more likely that individuals will comply with public health directives and more likely that compliance will not cause additional harms. The concept of safe harbor provisions can be broadened, creating the strategic imperative to ensure that community members have access to the resources and opportunities that prevent transmission of an infectious disease; this allows policies related to quarantine to align with a much deeper set of actions that ensure economic well-being, protect from discrimination, and attend to social connections. In Los Angeles County, California, this includes creating safe and welcoming places for immigrants (regardless of citizenship status) to access a full range of free health services (including vaccinations), establishing a legal assistance fund for immigrants, and decriminalizing economic activities such as street vending.

MULTIPLE FORMS OF OPPRESSION

Health-affirming policies are always limited in their effectiveness by practices and systems that perpetuate discrimination, maintain exposure to hazards, and continue grave injustices. For immigrants, the intersectionality of race, language, citizenship status, and economic position create, for many, exposures to multiple forms of oppression and marginalization that can negate the many benefits of inclusionary policies. Public health success depends on acknowledging this complexity and addressing the fundamental need for social, economic, and racial justice to ensure optimal health and well-being. Offering sanctuary policies at Los Angeles County health clinics is not sufficient if the possible change in the public charge rule can penalize immigrants who receive government services.

Health departments and public health practitioners will need to ensure that local, state, and federal officials enact laws and regulations that improve the conditions that shape immigrant health. The foundation of excellent public health practice recognizes our interconnectedness with one another and our environment. Effective disease control, prevention of chronic diseases, and promotion of health-affirming actions demand approaches that are comprehensive and rooted in an understanding of the social determinants of health. Nowhere is this clearer than in our obligation to ensure that public health policies and practices do not unfairly advantage or disadvantage some community members based on social hierarchies including race/ethnicity, sex, sexual orientation, gender identity, social class, and immigration status.

SOCIAL MOVEMENTS

Our history illustrates that a commitment to improving health means incorporating health practices in a justice framework that defines health as a social good belonging to everyone and as a human right. Many of our major advances in health status have occurred because of key social movements that resulted in significant reforms such as abolishing child labor, passing factory regulations, establishing housing codes, mandating an eight-hour workday and a guaranteed minimum wage, extending civil rights, and investing in community infrastructure such as sanitation, clean water, and a safe food supply. It is not possible to address immigrant health and well-being without connecting to current social movements across the United States tackling the fundamental issues that interfere with our public health mandate to ensure health and well-being for all. As for other vulnerable populations, immigrants are at the crossroads of these fundamental issues.