Take a stand commentary: how can medical anthropologists contribute to contemporary conversations on "illegal" im/migration and health?

Ethical and Epistemological Implications of Conducting Ethnographic Fieldwork as a Researcher-cum-Clinician in Brussels, Belgium

We draw on ethnographic fieldwork conducted in Brussels (Belgium) on the health care experiences of undocumented migrants. We explore the implications of the double position of the ethnographer, who is both a researcher and a practicing doctor. We describe how the intimate knowledge the ethnographer-cum-clinician holds about the health care system influenced and shaped the data collection, analysis and subsequent policy recommendations. We examine the ethical dilemmas in conducting research from an engaged position about care practices toward vulnerable populations in one's own professional field. We conclude with recommendations on how to challenge and interrupt complexities faced by multi-positioned ethnographers.

An ethnographic study of a community dentistry network serving Latine migrant farmworkers in Vermont: Barriers and access to care during the COVID-19 pandemic and beyond

BACKGROUND AND OBJECTIVES

Primary dental healthcare services are not accessible for a majority of Latino/a/e migrant farmworkers in the United States. Unmet dental health needs are well documented in larger states like California, Florida and New York, but the dental healthcare picture in smaller states is not well understood. The goal of this qualitative ethnographic study was to understand the delivery model of a free dentistry network serving Latine farmworkers in rural Vermont and specific barriers experienced at the network during the COVID-19 pandemic.

METHODS

Semi-structured ethnographic interviews were carried out with clinicians and transcripts were analysed using the constant comparison method to identify salient concerns and recommendations about barriers and delivery of care.

RESULTS

Clinicians highlighted structural issues including farmworkers' lack of time off work and absence of transportation to attend appointments, concerns about COVID-19 safety, concerns about immigration surveillance and language barriers. Providers outlined steps for improved service delivery including mobile care at local farms, enhanced intercultural training for providers, recognizing dentistry as essential healthcare at the state level and the leverage of existing appointments for preventive health. Drawing on anthropological frameworks of place-based care and deservingness of healthcare, our ethnographic findings emphasize the role of community dentistry in bridging gaps in migrant healthcare during and beyond the COVID-19 pandemic.

The Intersectional Impact of Disability and Immigration on Health: A Health Needs Assessment of Immigrants Living With Spinal Cord Injury in Houston, Texas

BACKGROUND

Immigrants with spinal cord injury (SCI) experience challenges with co-morbidities and lack of access to medical supplies and equipment. Much of the current disability and SCI literature does not include Latinx immigrants with SCI. To address this gap in knowledge, the present study explores the intersectional impact of disability and immigration on health as well as the health status and health needs of immigrants living with SCI.

METHODS

This community-partnered study is a secondary analysis of needs assessment data collected in February 2019 with 24 of the members of Living Hope Wheelchair Association, a nonprofit organization serving Latinx immigrants living with SCI in Houston, Texas.

RESULTS

Participants shared challenges with accessing healthcare, comorbidities, mental illness, transportation, and discrimination by healthcare professionals. They also shared difficulties accessing medical supplies, medical equipment, and the need for adaptations in their homes and vehicles.

CONCLUSION

The findings corroborate those of previous studies with people with SCI, but highlights additional layers of marginalization and challenges faced by immigrants living with SCI. More research is needed to understand the health needs and health status of this population, including their access to care and management of chronic diseases such as diabetes and heart disease. Findings support the need for public health and immigration policies to promote inclusion and equitable access to services as well as improve the health and quality of life of immigrants.

Chewing Revenge or Becoming Socially Desirable? Anger Rumination in Refugees and Immigrants Experiencing Racial Hostility: Latin-Americans in Spain

This paper explores how real scenarios of racial hostility and discrimination trigger anger rumination tendencies in refugees, asylum seekers and immigrants (hereafter RASI). Undergoing discrimination often leads to the development of negative thoughts and behaviors, and to a loss of meaning and self-worth. This could make young RASI particularly vulnerable to being recruited and exploited by extremist groups as they search for identity. We developed a picture-elicitation instrument (the PEI) to provide professionals with a tool that could identify groups of RASI according to their reactions to discrimination scenarios and explore how racial hostility might influence withdrawal levels. The tool was applied with the Anger Rumination Scale (ARS_19) to 509 RASI of Latin American origin living in Spain. Four categories were identified, according to how RASI processed anger when observing discrimination scenarios: “Social desirability”, “Chewing”, “Grudge”, and “Vengeful”. Further analyses showed that the youngest (18–29) fell under the “Grudge” and “Vengeful” categories and revealed more despair and social isolation. This study makes a positive contribution by being the first to investigate the problem of anger rumination in RASI undergoing racial hostility. Moreover, it equips professionals with two tools that, once validated, may help plan and implement strategies to reduce the impact of hostility on both RASI and their host societies.

When deservingness policies converge: US immigration enforcement, health reform and patient dumping

As immigration and health policy continue to be contentious topics globally, anthropologists must examine how policy creates notions of health-related deservingness, which may have broad consequences. This paper explores hidden relationships between immigration enforcement laws and the most recent health reform law in the United States, the Patient Protection and Affordable Care Act (ACA), which excludes immigrants from certain types of health services. Findings in this paper show how increasingly harsh immigration enforcement efforts provide health facilities a 'license to discriminate' against undocumented immigrants, resulting in some facilities 'dumping' undocumented patients or unlawfully transferring them from one hospital to another. Due to changes made through the ACA, patient dumping disproportionately complicates public hospitals' financial viability and may have consequences on public facilities' ability to provide care for all indigent patients. By focusing on the converging consequences of immigrant policing and health reform, findings in this paper ultimately show that examining deservingness assessments and how they become codified into legislation, which I call 'deservingness projects', can reveal broader elements of state power and demonstrate how such power extends beyond targeted populations. Exercises of state power can thus have 'spillover effects' that harm numerous vulnerable populations, highlighting the importance of medical anthropology in documenting the broad, hidden consequences of governmental actions that construct populations as undeserving of social services.

Navigating a fragmented health care landscape: DACA recipients' shifting access to health care

Deferred Action for Childhood Arrivals (DACA) recipients face an uncertain fate as their future in the United States is being debated. Yet even before the program was introduced in June 2012 and became endangered in September 2017, they encountered challenges in navigating a fragmented health care landscape throughout the United States. This paper focuses on DACA recipients' experiences in accessing health care throughout their lives, both before and after receiving DACA. We conducted semi-structured interviews and questionnaires with 30 DACA recipients living in Maryland between April-December 2016. Participants represented 13 countries of origin and ranged in age between 18 and 28. Results demonstrate that DACA recipients have had punctuated coverage throughout their lives and continue to face constrained access despite temporary gains in status. Health care access is further stratified within their mixed-status families. Participants have also experienced shifts in their health care coverage due to moving between jurisdictions with variable eligibility and changing life circumstances related to family, school, and employment. This article underscores the importance of examining young adult immigrants' access to care over time as they weather changes in the broader policy context and in highly variable contexts of reception nationwide, shaped by state, but also county and city policies and programs. The challenges and gaps in coverage DACA recipients face also underscore the need for both health care and immigration reform.

Buffering the Uneven Impact of the Affordable Care Act: Immigrant-serving Safety-net Providers in New Mexico

We conducted a study in early 2014 to document how the initial implementation of the Affordable Care Act (ACA) affected health care provision to different categories of immigrants from the perspective of health care providers in New Mexico. Though ACA navigators led enrollment, a range of providers nevertheless became involved by necessity, expressing concern about how immigrants were faring in the newly configured health care environment and taking on advocacy roles. Providers described interpreting shifting eligibility and coverage, attending to vulnerable under/uninsured patients, and negotiating new bureaucratic barriers for insured patients. Findings suggest that, like past efforts, this recent reform to the fragmented health care system has perpetuated a condition in which safety-net clinics and providers are left to buffer a widening gap for immigrant patients. With possible changes to the ACA ahead, safety-net providers' critical buffering roles will likely become more crucial, underscoring the necessity of examining their experiences with past reforms.

Neocolonialism and Health Care Access among Marshall Islanders in the United States

In the Marshall Islands, a history of extensive nuclear weapons testing and covert biomedical research, coupled with the U.S.'s ongoing military presence in the country, has severely compromised the health of the local population. Despite the U.S.'s culpability in producing ill health along with high rates of emigration from the islands to the mainland United States, the large portion of Marshallese who reside in the United States face substantial barriers to accessing health care. Drawing from ongoing field research with a Marshallese community in Arkansas, this article explores the multifaceted impediments that U.S.-based Marshall Islanders face in receiving medical treatment. Calling on an expansive and inclusive notion of neocolonialism, I argue that Marshallese structural vulnerability with regard to health and health care treatment derives from their status as neocolonial subjects and from their limited claims to health-related deservingness associated with this status. [Marshall Islanders, health care access, neocolonialism, radiation exposure, immigrant health] L̗ōmn̗ak ko rōttin̗o: Ilo M̗ajel̗, juon bwebwenato kōn kōmmālmel im nuclear baam̗ ko im ekkatak ko rōttin̗o̗ kōn wāwein an baijin ko jelōt armej, barāinwōt an to an ri tarinae ro an Amedka pād ilo aelōn̄ kein, em̗ōj an jelōt ājmour an armej ro ilo aelōn̄ kein. Men̄e alikkar bwe Amedka in ear jino nan̄inmej kein im ej un eo armej rein rej em̗m̗akūt jān āne kein āne er n̄an ioon Amedka, elōn̄ iaan ri M̗ajel̗ rein rej jelm̗ae elōn̄ apan̄ ko n̄an aer del̗o̗n̄e jikin ājmour ko. Jān ekkatak eo ej bōk jikin kiō, jerbal in ej etali kabōjrak rak kein rōlōn̄ im armej in M̗ajel̗ ro ioon Amedka in rej jelm̗ae ilo aer jibadōk lo̗k jikin taktō. Ilo an kar Amedka jibadōk juon jea eo eutiej imejān lal̗ in, ij kwal̗ok juon aō akweelel bwe apan̄ ko an armej in M̗ajel̗ ikijjeen ājmour im jikin taktō ej itok jān aer kar ri kōm̗akoko ilo an kar Amedka lelōn̄ l̗o̗k etan ilo mejān lal̗ im jān aer jab pukot jipan kein ej aer bwe kōn jōkjōk in.

Invisible students: institutional invisibility and access to education for undocumented children

Purpose

In Canada, undocumented children are “institutionally invisible” – their access to education to be found in unwritten and discretionary practices. Drawing on the experience of a three-year university-community partnership among researchers, institutional and community stakeholders, the purpose of this paper is to examine how undocumented children are constructed as excluded from school.

Design/methodology/approach

The establishment of this collaborative research space, helped to critically understand how this exclusion was maintained, and highlighted contradictory interpretations of policies and practices.

Findings

Proposing the analytical framework of “institutional invisibility”, the authors argue that issues of access and entitlement for undocumented children have to be often understood within unwritten and ambiguous policies and practices that make the lives of young people invisible to the institutional entities with which they interact.

Originality/value

The notion of institutional invisibility allows the authors to integrate the missing link between questions of access and deservingness. The paper also reflects on the role of action research in both documenting dynamics and pathways of institutional invisibility, as well as in initiating social change – as both horizontal, and vertical mobilisation.

Eating and Feeding at the Margins of the State: Barriers to Health Care for Undocumented Migrant Women and the "Clinical" Aspects of Food Assistance

In this article, I examine the various meanings of Mexican and Central American migrant women's utilization of private food assistance programs. I present findings from 20 months of ethnographic fieldwork conducted between 2008 and 2011 with migrant women, public health workers, and staff and volunteers of food assistance programs in Santa Barbara County, California. I discuss the barriers undocumented women face in accessing formal health care and the social and moral obligations that underpin these women's role in feeding others. I also document the ways in which private food assistance programs are orienting toward a focus on health in service delivery, and how women depend on provisions from these programs to support feeding practices at home. I argue that these findings are significant for current engagement by critical medical anthropologists in studying framings of "the clinic" and cultural beliefs about "deservingness."

Health at the Intersections of Precarious Documentation Status and Gender-Based Partner Violence

This article is based on qualitative research investigating Spanish-speaking immigrant women's experiences of gender-based intimate partner violence (GBPV) and help seeking in New Jersey (2006-2008). Methods included interviews with these women, health care and social service providers, and community members. This article reveals that as many immigrant women live at the intersections of structural, normalized, and gender-based partner violence, integrated social service responses emerge as key health care responses to GBPV. The health impacts of undocumented and precariously documented migration and GBPV demand policy interventions and dedication of resources to address the multi-faceted needs of this population.

Health workers' perceptions of access to care for children and pregnant women with precarious immigration status: health as a right or a privilege?

The Canadian government's recent cuts to healthcare coverage for refugee claimants has rekindled the debate in Canada about what medical services should be provided to individuals with precarious immigration status, and who should pay for these services. This article further explores this debate, focussing on the perceptions of healthcare workers in Montreal, a large multiethnic Canadian city. In April-June 2010, an online survey was conducted to assess how clinicians, administrators, and support staff in Montreal contend with the ethical and professional dilemmas raised by the issue of access to healthcare services for pregnant women and children who are partially or completely uninsured. Drawing on qualitative analysis of answers (n = 237) to three open-ended survey questions, we identify the discursive frameworks that our respondents mobilized when arguing for, or against, universal access to healthcare for uninsured patients. In doing so, we highlight how their positions relate to their self-evaluations of Canada's socioeconomic situation, as well as their ideological representations of, and sense of social connection to, precarious status immigrants. Interestingly, while abstract values lead some healthcare workers to perceive uninsured immigrants as "deserving" of universal access to healthcare, negative perceptions of these migrants, coupled with pragmatic considerations, pushed most workers to view the uninsured as "underserving" of free care. For a majority of our respondents, the right to healthcare of precarious status immigrants has become a "privilege", that as taxpayers, they are increasingly less willing to contribute to. We conclude by arguing for a reconsideration of access to healthcare as a right, and offer recommendations to move in this direction.

Intangible obstacles: health implications of stigmatization, structural violence, and fear among undocumented immigrants in France

This study identifies undocumented immigrants' obstacles to realizing their health care rights in France. The ethnographic fieldwork informing this study was carried out in Paris from March 2007 to July 2008. Research findings are based on (1) participant observation carried out in two grassroots health associations catering to undocumented immigrants in Paris (one providing legal and medical aid to undocumented immigrants from sub-Saharan Africa, and another focused specifically on assisting undocumented individuals seeking a visa for medical reasons, as well as women victims of domestic violence); (2) a review of legislative debates on the issue of healthcare access for undocumented immigrants in France, and (3) recently published reports on healthcare access for the undocumented in Europe. The paper analyzes how interaction among intangible factors - namely social stigmatization, precarious living conditions, and the climate of fear and suspicion generated by increasingly restrictive immigration policies - hinders undocumented immigrants' access to health care rights and, furthermore, minimizes immigrants' sense of entitlement to such rights in this European context. Intangible factors such as fear and suspicion have powerful "subjectivation" effects, which influence how both undocumented immigrants and their interlocutors (i.e., healthcare providers) think about "deservingness." Medical anthropology is in a unique position to demonstrate and theorize these factors and effects, which inform contemporary debates about migration and "health ethics."

How is health-related "deservingness" reckoned? Perspectives from unauthorized im/migrants in Tel Aviv

Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care "make sense"? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related "deservingness." In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, this article further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to--and, furthermore, from the perspectives of-- unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must consider the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other. The paper analyzes findings from a 29-month mixed-methods study conducted in Tel Aviv, Israel, that approached unauthorized im/migrants as subjects, rather than simply objects, of ethical deliberation. Participants' conceptions of health-related deservingness are investigated using two sources of data: (1) quantitative findings from a self-administered, closed-ended survey conducted with 170 im/migrant patients at an NGO-run Open Clinic (2002-2003), and (2) qualitative findings from the larger ethnographic study of which the survey was part (2000-2010). The study findings both (1) contradict commonly circulating assumptions that unauthorized im/migrants are "freeloaders," and (2) highlight the need for rigorous investigation of how unauthorized im/migrants, among other marginalized and vulnerable groups, conceptualize their own relative deservingness of health-related concern and investment.

Undocumented immigrants and their use of medical services in Orange County, California

Does an undocumented immigration status predict the use of medical services? To explore this question, this paper examines medical care utilization of undocumented Latino immigrants compared to Latino legal immigrants and citizens, and non-Latino whites in Orange County, California. Data were collected through a random sample telephone survey of 805 Latinos and 396 non-Hispanic whites between January 4 and January 30, 2006. Findings show that undocumented immigrants had relatively low incomes and were less likely to have medical insurance; experience a number of stresses in their lives; and underutilize medical services when compared to legal immigrants and citizens. Predictors of use of medical services are found to include undocumented immigration status, medical insurance, education, and gender. Undocumented Latinos were found to use medical services less than legal immigrants and citizens, and to rely more on clinic-based care when they do seek medical services.