Social Policy, Immigration Policy and Public Health

American views toward immigration have been a long winding thread in discussions of public health for more than a century. Recent rhetoric about immigrants as sources of disease and financial burdens echo language from the 19th century, though the groups of immigrants in question has changed over the decades. However, such rhetoric and the political climate that comes with it are something that health experts need to account for, and the histories of immigration and public health are keys to such an understanding.

In a new American Journal of Public Health editorial, Amy Fairchild, PhD, MPH, associate dean of academic affairs at the Texas A&M School of Public Health, describes the long history of immigration restrictions in the United States and how these laws have affected public perception of immigrant belonging and whether or not they are deserving of social benefits. Immigrants have long contributed to the American economy, yet they have often not been seen as deserving of the benefits of living in the country. According to Fairchild, the tensions between these two factors and the changing landscape of immigration and social welfare policy dramatically affect public health.

Some of the earliest negative views toward immigrants, much like present views, focused on disease. Today, diseases like Zika virus, tuberculosis, dengue fever, Chagas disease, chikungunya virus and schistosomiasis are often blamed on immigrants. The late 19th century similar fears of contagion spurred large-scale effort to carry out medical inspections of immigrants. This led to the screening of 25 million people coming into the United States, of which fewer than one-half of one percent were denied entry due to disease. Despite this, continued fears of disease led, in part, to the passage of the Immigration Act of 1924, which established national origin as a criterion for blocking immigration.

The 1924 law essentially ended immigration from Southern and Eastern Europe, but attention soon shifted to other nationalities, according to Fairchild. An influx of agricultural workers from Mexico and the Philippines ignited anxieties about tuberculosis during the Great Depression. The next decade or so saw the repatriation of many from these two countries, even those who were United States citizens.

By the 1960s, sentiments in the United States changed, leading to the Immigration Act of 1965, which stopped the use of national origin to limit immigration. The gates to America reopened. This period also saw the expansion of America’s welfare state with the advent of the Medicaid and Medicare programs. But by the 1980s and 1990s, there was mounting tension between immigration and social welfare policy, hastened by a growing immigrant population and fears that the AIDS crisis would overwhelm the American health care system and cause social welfare use to skyrocket.

In the mid-1990s, these tensions played out in the 1996 debate over welfare reform efforts that kept immigrants, both documented and undocumented, from accessing services like Medicaid and Medicare. Some of the harsher parts of that legislation were eliminated, Fairchild said, but the legal changes further reinforced the notion that immigrants were expected to play a major economic role without the benefits afforded citizens. Increasing economic inequality for citizens and non-citizens alike became a major issue through the late 2000s, as did the growing burden of health care access. The Patient Protection and Affordable Care Act, also called ‘Obamacare,’ attempted to ease the health care burden. However, undocumented immigrants were excluded from participating.

More recently, an increase in populist politics and anti-immigration rhetoric has been changing the nation’s political landscape and notions of immigration, disease and social welfare, Fairchild said. One type of populism attempts to unite parts of the population by pitting them against a perceived elite that shows favoritism toward a third group that is labeled as unworthy. This sort of exclusionary attitude and mistrust of social welfare programs in general stand to further change the political landscape in the United States over the near term.

This change and the continued growth of economic inequality are significant issues that public health policy will have to address, according to Fairchild. Attempts to improve public health policy will therefore need to reckon with ideas that portions of the population are less deserving and do not belong, which calls for a better understanding of the intertwined histories of immigration, fear of disease and public health. Failure to do so, Fairchild said, will ultimately harm the bottom 90 percent of Americans, whether they are citizens or immigrants, who are losing wealth as inequalities deepen.