• In Chicago, a young, undocumented man left paralyzed after falling from a building was deported to Mexico after being unable to pay his hospital bills.  The young man recently died in a Mexican hospital that was not able to tend to his needs.
• A recent editorial highlights the lack of legal representation available for undocumented immigrants in New York.
• The Obama administration recently created a new hotline for immigration detainees.
• Citizenship and Immigration Services is proposing a change to immigration procedures that can help prevent the separation of undocumented residents from spouses and children.
• Even though many Latinos in the U.S. disapprove of President Obama’s immigration policies, they favor the president over a Republican contender.
• A recent study conducted by researchers at Columbia University’s Mailman School of Public Health shows links between migrating at a young age and increased risk of psychotic disorders. Potential reasons for the increased risk include the stress of minority status, social changes, and vitamin D deficiencies that many immigrants experience after migrating.

• In Florida, drafts of legislation permitting undocumented immigrants restricted drivers’ licenses and access to health care for undocumented children are seen at odds with stricter immigration policies in other states.
• As part of the “Day of Justice,” students and Philadelphia locals assembled to discuss immigrant rights.
• A recent report in the Sacramento Business Journal highlights the economic impact of unauthorized immigrants, specifically noting that unauthorized immigrants in California paid $2.7 billion in taxes in 2010.

International News:

• Roma immigrants are a focus of debate in the French presidential election.
• Reflecting on his experience with U.S. immigration officials, English rapper Wiley explains that his new album will focus on serious social issues such as immigration.
• British Pop artist Adam Ant attracted attention when police entered his home and arrested a woman who overstayed her visa.
• Well-educated immigrants, like Ryan Savage, an American immigrant to Finland, are unable to find work. After poor job prospects, Savage left the country and returned to the United States.

A recent New York Times article by John Leland recounted the lengthy medical history of Raymond Fok, an uninsured and undocumented immigrant who ended up marooned at New York City’s Downtown Hospital for 19 months after surviving a stroke. Although suffering from chronic health problems, including kidney failure, and initially in need of acute care, Mr. Fok remained in the hospital long after his initial emergency because he had no other place to go.

Without insurance or public benefits, numerous immigrants in the U.S. find similar fates in public hospitals, learning that without chronic or community-based services to assist them in recovery, they cannot be discharged. Rather than qualifying for a home health aide, or getting transferred to a nursing home, Mr. Fok’s status left him in the expensive care of an already cash-strapped public hospital. As Leland writes: “Mr. Fok’s immigration status never kept him from receiving treatment, but it helped make sure that his care would be delivered in the most expensive setting possible and in a place no one wants to spend more time than necessary.”

Mr. Fok was a “prisoner” by default, held captive only for lack of other options. Ultimately, he was transferred to the care of his family, who had been difficult to locate (many undocumented patients will not disclose family contacts for fear that the information will be shared with immigration authorities), and were poorly equipped to care for him. He had no benefits or assistance to help him with his long-term recovery. Back at home, with little or no support, he appeared to lose much of the mobility and verbal skills he had rebuilt in the hospital after his stroke.

In my last post, I discussed the research I have conducted with undocumented immigrants residing in psychiatric hospitals who, like Mr. Fok, remain hospitalized for lack of less restrictive and more community-based options. They too are “prisoners” by default, often eager to leave these isolated residences, but lacking other places willing to provide for their care. Particularly for those with mental health problems, long-term hospitalization in a state psychiatric institution can be more damaging than recuperative, and community-based services provide a crucial gateway towards full recovery.

Many patients I have interviewed show sufficient improvement by clinical measures, but transfer to further community-based services is all but impossible without qualifying for additional institutional supports such as Medicaid, supportive housing, and disability pensions. Others cycle through episodes of acute illness but, without a vision or a hope of future discharge, seem unable to claim a foothold in recovery. Some individuals have remained hospitalized for decades even as family members have gained citizenship and carried on with their lives. Hospital staff and administrators often bear witness to the damage caused by long-term institutionalization, yet remain unable to facilitate discharge.

The costs of confinement—either to public hospitals or to state psychiatric institutions—are enormous and excessively wasteful of public resources. Just last week, the New York Times released another report on the costs of unnecessary acute care for undocumented patients at New York City’s overburdened public hospitals. Although comparing costs is always difficult, it is much more expensive to treat mental health issues within a state psychiatric hospital than to provide community-based care and services. Without a change in immigration laws, in Medicaid and Medicare eligibility criteria, or both, we can expect these expenses to continue rising for public hospitals. With Congress enacting laws to reign in the costs of Medicaid and Medicare, and with state budgets badly strapped for cash, hospitals are tightening the belt on already slim budget margins. Under these circumstances, it is imperative that we face facts: improving access to community services will not only facilitate better recovery for many undocumented immigrants, but also dramatically reduce wasteful spending on costly acute care services.

For now, few clear alternatives exist for patients like Mr. Fok. Although no one would advocate for the unnecessary waste of resource-intensive care, the current system leaves undocumented immigrants with few other options. Discharging a patient to less restrictive and more supportive care is wonderful, but only if that person also has a place to live and a means of making a living. As cases like this one illustrate, the situation for immigrants confined to institutions is embedded, by default, within the overlapping (and seemingly insurmountable) crises in the U.S. health care and immigration systems.

If immigrants with chronic health concerns received the benefits available to citizens, then they would be better supported in managing their illnesses (mental or physical) and charting their paths to recovery. And, crucially, this would be accomplished at much lower cost to states and healthcare facilities. Continued penalization of the most vulnerable immigrants not only lays the groundwork for gross rights violations, but also bars their access to the tools of their own recovery—recovery, it is worth noting, that would save our health systems millions of dollars a year.

Nora Kenworthy is a PhD student in Sociomedical Sciences at Columbia University, where she is also a fellow with the Columbia Population Research Center. Her work focuses on political determinants of health, and how health systems and health-seeking impact citizenship, political participation, and social belonging. She recently completed a research project on undocumented immigrants in psychiatric institutions in the U.S., with funding from the Center to Study Recovery in Social Contexts.

Cite this:

Kenworthy, Nora. 2012. “When the Ward is Your Mooring: The Human and Economic Costs of Long-Term Acute Care for Undocumented Immigrants in the U.S.” Accessed [date] at  http://accessdeniedblog.wordpress.com/2012/01/12/when-the-ward-…nora-kenworthy/.

Over the past few years, stories have trickled into the U.S. national media about hospitals struggling to cope with the burden of caring for undocumented immigrants who lack insurance and are ineligible for benefits. These reports, including a recent series by New York Times reporter Kevin Sack and an even more recent NYT piece by Sam Roberts, feature accounts of chronically-ill patients being removed from dialysis, or ‘repatriated’ to their countries of origin in comas, to be cared for by long-lost and poorly-equipped relatives. As Luis Plascencia wrote on this blog a few years ago, these rare glimpses into hospital decision-making processes indicate that rising costs and non-existent legal protections for immigrants have led to a ‘privatization’ and ‘outsourcing’ of deportation by health care institutions.

To date, this meager public attention has focused exclusively on hospitals treating physical illnesses. Virtually no mention has been made of how psychiatric and mental health institutions handle undocumented immigrants. Several reports—for example, by the ACLU / Human Rights Watch, Texas Appleseed, and the New York Times—have shed light on the fragile mental health of immigrants in detention. Yet we know little about the policies of either psychiatric hospitals or state offices of mental health regarding undocumented immigrants.

This population faces a nexus of vulnerabilities that makes them among the most socially isolated and—given the current political climate—most undesirable groups in the U.S. As poor members of racial or ethnic minorities with significant histories of psychiatric illness, they are not only more likely to become undocumented, either before or during care, but also especially prone to unlawful or unethical deportation, removal, or repatriation.

Since 2008 I have worked, as a graduate student and researcher, with a team of academics, clinicians and administrators to study the unique situation and acute needs of a group of undocumented immigrants residing within a state psychiatric institution in the Northeastern U.S. Unwilling to repatriate its undocumented patients against their wishes or to turn them over to Immigrations and Customs Enforcement (ICE) for deportation, the hospital struggles to find ways to transfer patients to less-restrictive settings like group homes or community-based services and thereby continue supporting their recovery.  But there’s a problem: patients’ undocumented status makes them ineligible for medical and disability benefits, without which they are hard-pressed to access supported accommodation and psychiatric care in community settings. As a result, the asylum setting becomes a kind of reservoir—a hospitalized sanctuary-cum-holding cell—for immigrants who are unable to be discharged but unlikely to ever obtain legal status.

Our research indicates that immigrants often lose crucial documentation during periods of mental illness or hospitalization. Hospital staff struggle mightily to help immigrants obtain legal status, although they lack the necessary training in immigration law. Barred from community-based services, and often lacking strong English skills, patients are ill-equipped to navigate the bureaucratic hurdles necessary to obtain documentation. Hospitals like this offer unlikely shelter to a population that has no other recourse to treatment, housing, or support. But confinement is a strange instrument of kindness, one that hospital residents and clinicians alike find confusing as well as morally and legally uncomfortable.

Scarce information is available about how other psychiatric institutions handle undocumented immigrant patients, though few may be as protective of their charges, or as reluctant to opt for repatriation and deportation, as the one with which we have worked.  The few reports we have obtained from other facilities indicate they often rely on “voluntary repatriation” for undocumented patients. How can institutions guarantee that these removals are voluntary, or that full and informed consent has been obtained?

According to the scant information we are able to access, hospitals employ a wide variety of strategies in coping with such populations—strategies that include repatriation and removal, and that rarely attract public notice. We need more publicly accessible data about how many patients are voluntarily or forcibly removed from psychiatric institutions on the basis of their immigration status each year. At present, hospitals and state offices of mental health have no incentives to track or share this data. In at least one case, documented in a 2010 Human Rights Watch report, immigrants were sent directly from mental health facilities into detention.

Corporations like Mexcare allow U.S. hospitals to outsource the unlawful “voluntary” removal of ill patients to their countries of origin. For a healthy profit, they absorb responsibility for the dirty work of removing patients from the health system, flying them home in medically-equipped jets, and even tracking down family members on whom responsibility for acutely ill persons is thrust, regardless of whether they, or the local health care systems, are capable of providing adequate care.

For immigrants with mental health conditions, the boundaries of responsibility are even fuzzier. Psychiatric illness further clouds issues of consent and accountability around repatriation, potentially rendering patients less able to: 1) give consent; 2) articulate their wishes; 3) be informed about their rights; 4) access legal services; 5) contest removal; and 6) draw attention to their cases.  State policy, de-facto administrative practice, and the ethical obligations of physicians and hospitals may differ considerably regarding issues of care, discharge, and responsibility.

Current policy options are fraught with difficulties. Mental health advocates argue that patients should be entitled to more community-based care options, but these rarely exist for those without benefits. With immigration laws tightening and becoming more punitive by the day, gaining documentation is elusive for many immigrant groups, and it is especially difficult for those struggling with mental illness and hospitalization. This population occupies an interstitial space between immigration laws, which are increasingly stringent, and our country’s troubled psychiatric institutions, which provide ad-hoc shelter for mounting numbers of homeless, indigent, and socially abandoned individuals.

In the short term, hospitalization should never prevent immigrants from seeking documentation. Hospital staff need more assistance in helping patients with their immigration casework, and the mental health system must take steps to ensure patients do not unnecessarily lose documentation, or opportunities to become documented, because they struggle with mental health problems or are isolated in psychiatric hospitals.

These sites of strange refuge, and their marooned charges, will likely become more common unless immigration and mental health policies are dramatically improved. They deserve more attention from academics and policy-makers alike, and we owe it to those untold numbers of immigrants facing confinement or unjust repatriation to raise the veil of secrecy about the institutions involved in their care.

Nora Kenworthy is a PhD student in Sociomedical Sciences at Columbia University, where she is also a fellow with the Columbia Population Research Center. Her work focuses on political determinants of health, and how health systems and health-seeking impact citizenship, political participation, and social belonging. She recently completed a research project on undocumented immigrants in psychiatric institutions in the U.S., with funding from the Center to Study Recovery in Social Contexts.

Cite this:

Kenworthy, Nora. 2012. “The Psychiatric Hospital as Safe House?  Strange Asylum for Undocumented Immigrants with Mental Health Needs.” Accessed [date] at http://accessdeniedblog.wordpress.com/2012/01/04/the-psychiatric-hospital-as-safe-house-strange-asylum-for-undocumented-immigrants-with-mental-health-needs-nora-kenworthy/.

Although ICE’s Secure Communities initiative claims to prioritize “the removal of criminal aliens, those who pose a threat to public safety, and repeat immigration violators,” recent national reports by PBS Frontline and the Applied Research Center (ARC) indicate that most immigrants taken into ICE custody have no serious criminal history—and, moreover, that a growing number are parents with dependent children.

According to a recent Frontline special entitled “Lost In Detention,” not only are undocumented immigrants taken into ICE custody increasingly likely to be parents, often of U.S. citizen children, but they also have lived in the United States, on average, for more than 11 years. Often such cases begin with a routine traffic violation and a missing driver’s license, followed by a fingerprint check against both FBI and Department of Homeland Security national databases.

Other cases begin with domestic violence complaints. According to ARC’s recent report “Shattered Families,” local police commonly apprehend not only perpetrators but also victims of domestic violence who happen to be undocumented. Both are fingerprinted and detained by ICE, and if children are involved, they are placed in foster care. Both Frontline and ARC suggest that Secure Communities combined with longstanding 287(g) agreements, which grant local police authorization and resources to enforce immigration law, have led to the upswing in detention of non-criminals – including victims of domestic violence. Another contributing factor is the rapid growth of for-profit detention centers, whose corporate owners have lobbied for legislation increasing immigration detention.

ARC reports that at least 5,100 children across 22 states are currently in foster care because their parents have been either detained or deported. In counties with 287(g) agreements, children in foster care are roughly 29 percent more likely than foster children in other counties to have a detained or deported parent. If this trend continues, ARC estimates that 15,000 more children will face similar cases over the next five years. The problem starts with aggressive immigration enforcement, but indefinite detention and a lack of clear Child Protective Services (CPS) policies regarding deported parents disrupt and often prevent reunification.

In a report titled “Disappearing Parents,” University of Arizona professor Nina Rabin outlines the scope, magnitude, and implications of this problem. First, ICE officials can often choose whether or not to initiate detention or deportation proceedings, but they rarely exercise their discretionary power to avoid separating children and parents. Once detained, parents have little control over the placement of their children, especially when they hope for placement with undocumented relatives. Given parents’ inability to communicate with CPS, they cannot adhere to its reunification plans – a problem that becomes exacerbated when they are moved to faraway detention facilities. In the absence of established protocols, the decision about whether parents may maintain contact with their children is in CPS agents’ hands. According to Rabin, criminalization actually encourages CPS personnel to “write off” immigrants in detention and assume that families will not be reunified.

Neither fighting nor accepting one’s deportation is likely to shorten the reunification process. If parents choose to fight, then the length of immigration proceedings can easily exceed the deadlines set by CPS unification plans. If parents resign themselves to deportation, CPS may declare that their children will be better off in the U.S. and refuse to send them abroad. In other cases, CPS may require that parents find a job, or complete parenting classes in their home country within a set timeline, then petition to terminate parental rights if the deadline is not met.

Although ICE frames family separation as “collateral damage” of its efforts to deport people who pose a “true public safety or national security threat,” it is no rare occurrence. In fact, most deportations now result in such collateral damage. According to ICE deputy director Kumar Kibble, interviewed by Frontline, fewer than half of the agency’s record 400,000 deportations in fiscal year 2010 involved “criminal removals” – even under ICE’s broad definition of “criminal,” which includes repeat border crossers. To take one state as an example, Jerry Stermer, senior advisor to Illinois governor Pat Quinn, told Frontline that fewer than 20 percent of deportees from that state had been convicted of a serious crime.

Such statistics have not deterred ICE officials, who have normalized non-criminal removal by setting 2010’s record 400,000 deportations as the new standard. According to former ICE field office director Michael Rozos on Frontline, the agency’s budget rests on an agreement with Congress to maintain this 2010 “achievement”; any fewer would result in future budget cuts. ICE met its goal in the 2011 fiscal year through a slight increase in “criminal” deportations, but the proportion of deportees with felony convictions was still low: only about 40 percent. To meet its annual target, Rozos reports that ICE encourages agents to arrest every undocumented person within reach, including “collateral apprehensions,” to “get the numbers moved up.” Indeed, in a February 2010 internal memo, the agency directed its personnel to heighten – rather than discourage – non-criminal deportations. Although both ICE and President Obama have taken note of the ARC report and expressed a commitment to family unification, non-criminal arrests are driven by a numbers game with high stakes for families and children.

Secure Communities may have provided ICE with an effective tool for casting a wide net and maximizing its deportation figures, but the program has strayed far from its original objective – to target the “worst of the worst” – and instead become an indiscriminate mechanism for putting a record number of parents, many of them otherwise upstanding long-term residents, on a path to deportation. As the reports reviewed here clearly demonstrate, ICE’s repurposing of a reasonable immigration strategy has severe consequences; it is tearing families apart, thereby routing parents through a system with numerous health risks and jeopardizing their children’s mental health and well-being. No matter how much CPS protocols may improve, it appears that ICE practices will continue to harm families as long as the language of “security” is regularly perverted to justify the deportation of non-criminals.

Rachel Stonecipher is an honors student at Southern Methodist University, where she is also a member of the Hyer Society. A double-major in anthropology and cinema-television, she spent the summer of 2011 conducting ethnographic research on the social structure of im/migrant rights activism in Tucson, Arizona, with support from a Richter Fellowship.

Cite this:

Stonecipher, Rachel. 2011. “Shattered by Security: The Impact of Secure Communities on Families.” Accessed (date) at http://accessdeniedblog.wordpress.com/2011/12/15/shattered-by-security-the-impact-of-secure-communities-on-families-rachel-stonecipher/

• The Supreme Court announced that it would begin hearing arguments about state immigration laws in April, beginning with Arizona law SB1070, the first in a series of state laws targeting undocumented immigrants.  Justice Elena Kagan is recusing herself from hearing the arguments about Arizona’s immigration law on account of filing a lawsuit against Arizona during her tenure as solicitor general.
• Alabama’s attorney general, Luther Strange, recommends the state legislature repeal some parts of the state’s new law until federal courts clarify states’ roles in setting immigration policy.
• With a new training program for lawyers and enforcement officials, The Department of Homeland Security hopes to speed up deportations of criminals and suspend deportations of undocumented immigrants without a criminal record.
• Recent statistics show that border apprehensions are down 25% from last year, and that the number of “illegal border crossings” is lower than it has been in nearly 40 years.
• Earlier this month in Texas, an 18-year-old named Joaquin Luna, Jr., took his own life, leaving behind a note that reflected Luna’s lost sense of hope for realizing his goals.  Some immigrant rights groups note that Luna’s suicide points to the significant psychological pressures of being an undocumented resident in the United States.
• After a rent increase and a new proof of legal status requirement, residents of a mobile home park in New Mexico worry they may have to move.
• Arizona Sherriff Joe Arpaio, whose stance on immigration has given him national notoriety among political conservatives, is accused of “botching” sex-crime cases.  Many of victims of the sex-crimes, which include child molestation, were children of undocumented immigrants.
• In a recent blog post, The Immigration Policy Center critiqued the American Heritage Dictionary for including “anchor babies” as a new term.  In response, the dictionary’s editor revised the term to reflect its meaning as a slur.
• A Colombian Immigrant and Brooklyn resident wrongfully accused of sexual assault discusses how the allegations have negatively impacted his life.
• Successes of undocumented immigrants’ children have also been featured in recent news, as demonstrated by M.D. Anderson Cancer Center President, Ronald DePinho’s reflection on his father’s struggles as an undocumented immigrant.

Research Network

• Place, Migration & Health, a new website dedicated to research on migration and health, has just launched.

• In the United States, deportation rates reach some of the highest levels in the nation’s history, even though deportation policies under the Obama administration are inconsistent.
• A new UCLA report analyzed anti-immigrant radio rhetoric, suggesting potential links to anti-immigrant media and increased rates of anti-Latino hate crimes.
• Immigration has been a persistent theme in the republican presidential nomination debates, particularly for former Massachusetts Governor Mitt Romney and Texas Governor Rick Perry. In one debate, the two nomination hopefuls sparred over Romney hiring a lawn maintenance company that allegedly employed undocumented workers.   Both Romney and Perry have critiqued each other for legislation they supported in their home states.  Rick Perry signed a law that allowed children of undocumented laborers to pay in-state tuition while attending Texas colleges (a measure supported by former president Bill Clinton), and under the Massachusetts health care law Romney signed in 2006, undocumented immigrants are allowed access to medical services through the state’s Health Safety Net fund.  Romney’s rivals have critiqued the Massachusetts law, and Romney has responded by claiming his democratic successor is responsible for details surrounding the health safety net services.
• Russell Pearce, who played a strong role in designing Arizona’s Immigration Law SB1070 lost his state senate seat in a recall election on November 8, 2011.
• College students in Georgia have requested that the state Board of Regents rescind a policy banning undocumented immigrants from attending Georgia colleges.

International News:

• In Greece, undocumented immigrants are being blamed for problems facing the nation.
• In keeping with the International Labor Organization’s Domestic Workers Convention ratified last spring, numerous governments, among them Hong Kong, Singapore, Jordan, and Kuwait, have agreed to expand protections for domestic workers after hearing reports of exploitation and abuse.
• In Canada, British Columbia is expecting to have more authority in the types of immigrants the province accepts in 2012

• A Federal District Court upheld Alabama’s immigration law that requires law enforcement officials to attempt to verify a person’s immigration status during traffic stops or arrests if they “reasonably suspect” the person is in the country illegally.  As a result of the ruling, some immigrant families have removed their children from Alabama schools to avoid attention from law enforcement.  Other families have moved out of the state altogether, some just a few hours after the court ruling, leaving behind their homes and belongings.
• A Colorado farmer faced a labor shortage after hiring fewer immigrant workers through the federal H-2A program this year.  With high unemployment rates, the farmer assumed local workers would take on agricultural jobs paying $10.50 per hour, but soon discovered that local workers were unwilling to engage in the physically demanding work.  Farmworker shortages, believed to be connected with recent immigration legislation, have also occurred in Georgia, costing the state an estimated $75 million.
• Absent from the 29^th annual Border Governors Conference were three out of four governors of U.S. states that share a border with Mexico. Governors Rick Perry (TX), Jan Brewer (AZ), and Jerry Brown (CA), all missed the conference, making Governor Susana Martinez (NM) the only U.S. governor in attendance.
• In New York City, the Bloomberg Administration announced its support for a bill that would hinder federal agencies from deporting inmates about to be released from Rikers Island Correctional Facility.
• A fatal automobile accident involving an undocumented immigrant driving drunk has focused political attention on Massachusetts Governor Deval Patrick for not taking part in programs aimed to deport criminals.
• “Illegal re-entry” into the U.S. has become a high priority for the Obama administration, and many deported immigrants continue to cross the border in an effort to reunite with their families that live in the U.S.

International News

• As immigration legislation tightens worldwide, immigrant detention becomes an increasingly profitable industry for private detention companies.
• Some U.K. cabinet members’ appear to have divided stances on immigration policy.
• Japan sends North Korean refugees to South Korea at their request.

• The Centers for Medicare and Medicaid Services is partnering with community organizations that support immigrants to share information about health programs such as Medicare, Medicaid, and the Children’s Health Insurance Program. A particular focus of these education efforts is to explain how Health Reform will benefit immigrants. Undocumented immigrants are still barred from receiving federal benefits, but legal immigrants may be eligible for some programs even before their five-year waiting period is up.
• Obama’s Secure Communities program continues to attract criticism, particularly for its “confusing” stance regarding who should be prioritized for deportation. Despite statements by the Obama administration that the program should only target the most serious criminal offenders, reports continue that immigrants are being detained and deported for traffic violations and other minor infractions. Some local law enforcement representatives worry that this approach undermines trust and can endanger community policing.
• A report released this week documents widespread abuses by the US Border Patrol including denying food and water to people in custody. The humanitarian organization No More Deaths (which is a ministry of the Unitarian Universalist Church of Tucson) released the report,  A Culture of Cruelty, that is based on interviews with nearly 13,000 detainees. Other alleged abuses include being beaten, psychological mistreatment, separating family members,  and overcrowding.
• A study in the Harvard Educational Review reports that children of undocumented immigrants face many educational, social, and psychological obstacles in their development that stem from their parents’ illegal status.
• The United States Court of Appeals for the Ninth Circuit recognized the right of day laborers to congregate and solicit work as part of their right to free speech. This law could impact anti-soliciting ordinances in towns across the country.

International News

• The Dominican Republic deports Haitian refugees.
• Tunisian migrants protest forced repatriation and battle with police on Lampedusa.
• Australian legislators unable to reach an agreement for processing asylum seekers.
• British immigration officials hope to return an illegal immigrant to Pakistan who has been in hospital for a year. According to the BBC report, a UK Border Agency spokeswoman said: “The NHS is a national, not an international, health service.”

Why propose another concept that appears to be a variation on a well-established theme … social suffering, the social production of disease and distress, the effects of violence of all kinds upon people and communities throughout the world? And why select a particular population like Latino migrants to represent how insidious and gripping structural vulnerability can be to one’s health and livelihood?

In a special issue of the journal Medical Anthropology, “Structural Vulnerability: Latino Migrants in the United States,” [1] the social science concept of structural vulnerability is introduced and put to use by medical anthropologists familiar with the plight of Latino migrants in the United States. Structural vulnerability refers to one’s position in social hierarchies that imposes physical-emotional suffering on specific population groups and individuals in patterned ways. It is the product of class-based economic exploitation and cultural, gender/sexual, and racialized discrimination that are embodied and often result in the formation of subjectivities that are socially depreciated. The vulnerability of an individual is produced by his or her location in a hierarchical social order and its diverse networks of power relationships and effects.[2] Latino migrants, regardless of their legal status, are scapegoated and denigrated as they are placed at the lowest rungs of U.S. society while being criminalized as ‘‘illegal aliens.’’ This racialized ordering and criminalized othering result in a routinized, lived experience shared by Latinos throughout the United States; the impact such positioning has on their social and health status is immense. However, structural vulnerability is not unique to Latino migrants in the United States, as it also applies to the poor, the sexually stigmatized, the medically uninsured, people of color, the disabled, the formerly incarcerated, the drug addicted, runaways, throwaways and castaways around the world.

The notion of structural vulnerability builds upon the seminal work of medical anthropologists – Scheper-Hughes, Kleinman, Farmer, Singer to name a few – who not only have documented the ravages of structural vulnerability, but also are committed to transforming the institutional practices of medicine and public health, to realizing their potential as not only curative but also healing practices. And toward that end, it is vitally important to transcend conventional notions of how pathology occurs and recognize there is much more that can be done to mitigate mortality and morbidity through human commitment, ingenuity, and action.

Each of the contributors to this special issue uses the concept of structural vulnerability to deepen understanding of health and well-being:

• Linda Green questions how genuinely U.S. immigration policy can be reformed when it is linked to neoliberal global economic forces that compel Latin Americans to leave their homelands in pursuit of work and viable livelihoods and, moreover, when it regards health care as a for-profit enterprise.
• Elizabeth Cartwright describes how regardless of whether Latino workers are citizens or non-citizens, legally documented or not, their access to health and health care in the United States reflects the broader inequities of the health care system. Her piece further discloses that there are no automatic rights or unimpeded access to health care even for Latinos well on their way to naturalization.
• Sandy Smith-Nonini argues that the levels of worker injuries Latino laborers endure are tied to the structural violence of the North American Free Trade Agreement (NAFTA) and the suppression of union and worker rights as well as immigration status and deregulation of labor markets and protections.
• Michael Duke asserts that Latino workers trying to make sense of their plight often internalize notions of race and ethnicity that compel workers to exercise modes of self-governance and self-regulation that reinforce the organization of labor that places them in this predicament in the first place.
• James Quesada  describes  Latino workers internalizing the negative depictions and popular stereotypes against them while striving to  escape the stigma and sanctions thrust upon them.
• Finally, Seth Holmes portrays how everyone, from Latino workers to the American citizens that employ them, is implicated in power dynamics that are harmful –albeit to different degrees — to everyone.[3]

By introducing structural vulnerability into our lexicon, in some small way, all the authors of this special issue are committed to contributing to the establishment and practice of a to-be realized, genuine practice of social medicine.

Click below to read a newly published commentary in Medical Anthropology Quarterly in which three of AccessDenied’s founders consider precisely this question.[1] We invite your comments and reactions below, and we hope the piece will encourage additional scholars, clinicians, public health professionals, migrant activists, and others to join our conversation here at AccessDenied as readers and/or contributors.

Take a Stand Commentary: How Can Medical Anthropologists Contribute to Contemporary Conversations on “Illegal” Im/migration and Health? Medical Anthropology Quarterly Sarah S. Willen, Jessica Mulligan, Heide Castañeda. Vol. 25, Issue 3, pp. 331–356.

ABSTRACT: Of the estimated 214 million people who have migrated from poorer to richer countries in search of a better life, between 20 and 30 million have migrated on an unauthorized, or “illegal,” basis. All have health needs, or will in the future, yet most are denied health care available to citizens and authorized residents. To many, unauthorized im/migrants’ exclusion intuitively “makes sense.” As scholars of health, social justice, and human rights, we find this logic deeply flawed and are committed to advancing a constructive program of engaged critique. In this commentary, we call on medical anthropologists to claim an active role in reframing scholarly and public debate about this pressing global health issue. We outline four key theoretical issues and five action steps that will help us sharpen our research agenda and translate ourselves for colleagues in partner disciplines and for broader audiences engaged in policymaking, politics, public health, and clinical practice. [unauthorized im/migration, “illegality,” social determinants of health, “deservingness,” public anthropology]