Home > Health Reform, Recent Post > Illegal Immigrants as the Last Frontier of Welfare – Didier Fassin

Illegal Immigrants as the Last Frontier of Welfare – Didier Fassin


Didier Fassin
Institute for Advanced Study, Princeton

This is a note of circumstance in two ways. First, it was written as the prelude to a lecture on “Global Health” delivered at the Conference of the Society for Medical Anthropology at Yale University in September 2009; it must therefore be placed in this broader perspective. Second, it refers to a scene I found significant in the early period of the debate around health care reform in the United States. However, I do not want to be seen as following the crowd of critics of this courageous and indispensable reform always deferred. Thus this fragment must be considered simultaneously within this specific context and outside of it, since it is meant to evoke the larger question of which members a society may exclude from its solidarity (and I refer here to “members” because people who live, work and die in a given society can claim membership whatever their citizenship and status).

Following Barack Obama’s much celebrated speech to defend his health plan before Congress on September 10 of this year, one anecdotal event received much attention: the interpellation of the President by infamous Representative Joe Wilson, who accused him of lying. Much indignation has been raised by this lack of civility or evidence of racism, depending on interpretations, but few have  commented on the matter that provoked this gross accusation of lying: the assertion that no illegal immigrants would receive benefits under the plan in preparation.

Whatever appreciation one may have of this assertion – whether it is true or false, good or bad – the remarkable fact is that it seems to take for granted a broad political consensus supporting the exclusion of undocumented foreigners from the plan for health reform. The President discarded the claim made by his opponents that he might think otherwise as obviously absurd and bogus, just as he protested  the claim that he is planning to set up panels of bureaucrats with the power to kill off senior citizens. In other words, saying that illegal immigrants would be included in the reform can only be a mere invention to discredit the government, as if this hypothesis were not only improbable but also unthinkable.

The implicit meaning of this reasoning is thus that the lowest common denominator for the reform is that it must draw a line within the population living in the country. If health is to be recognized as a common good, which is probably the most crucial issue of the present plan and its major ideological innovation, then it is necessary to define the moral community that deserves, or at least is entitled to benefit, from this collective solidarity. These notions – common good and moral community – are intricately related, but they may need some theoretical clarification and even more historical perspective.

It is certainly one of the most significant aspects of what Karl Polanyi coined as the “great transformation” characteristic of modernity that health has been recognized as a public responsibility rather than just a private matter and that we thus may be “in care of the state,” according to Abram de Swaan’s felicitous expression. This conception derives from the fact that health has increasingly been considered as a common weal and not just a natural given. One may remember that Jean-Jacques Rousseau, in the introduction to his 1754 Discourse on Inequality, distinguished between physical and moral inequality; for him, as for his contemporaries, disparities inscribed in the body were excluded from the political. One century later, they had become part of the progressive project of the hygienists.

It took one hundred more years to see this idea formally accepted at an international level. With the birth of international institutions like the World Health Organization in 1948, the idea of a global common good seemed to be on its way, just as the utopia of a world moral community was inscribed in the foundational texts of the United Nations in the aftermath of the Second World War. However, sixty years later, the idea and the utopia are still more present in the rhetoric of international agencies or the imaginary of non-governmental organizations than in the empirical facts anthropologists observe in their fieldwork.

Returning to the U.S. scene, to Barack Obama’s reform, and to Joe Wilson’s outrage, this is what the recent episode in Congress reminds us: that health remains largely a national affair rather than a global question, that its recognition as a common good has to be conquered over individualistic conservatism, and that within each specific context the necessary condition for obtaining this recognition is the delimitation of a moral community that separates the entitled from the excluded, the deserving from the undeserving. In its soft form, this means that those not entitled to public social protection may still benefit from compassionate help through private charity organizations. In its strong version, it implies that excluded persons may be left without any treatment or preventive care.

This point should be emphasized. That illegal immigrants may be absent from health reform is highly significant. Far from being a marginal dimension of this political project, as one might infer from the fact that the population concerned is itself marginal, it is a crucial test for policies. Just as Hannah Arendt asserted that the fate of refugees in the first half of the twentieth century was intimately related to the decline of the nation-state, we must consider the political treatment of immigrants as a major challenge for the social state in the early twenty-first century.  In fact, these two categories are less distinct than we might think, since today’s undocumented foreigners are often none other than rejected asylum-seekers. Even in a globalized world, the right to health is bound to state policies in the same way that civil rights are. Thus the ultimate moral of this recent Congressional fable may be simply that global health starts at home.

Didier Fassin, MD, PhD, is James D. Wolfensohn Professor in the School of Social Science at the Institute for Advanced Study at Princeton and the author of seven books, including When Bodies Remember: Experiences and Politics of AIDS in South Africa (2007) and The Empire of Trauma: An Inquiry into the Condition of Victimhood (2009), as well as numerous articles in social science and medical journals.  Fassin’s body of work is situated at the intersection of the theoretical and ethnographic foundations of the main areas of anthropology—social, cultural, political, medical. Trained as a medical doctor, he has conducted field studies in Senegal, Ecuador, South Africa, and France, leading to publications that have illuminated important aspects of urban and maternal health, public health policy, social disparities in health, and the AIDS epidemic. He recently turned to a new area that he calls “critical moral anthropology.” He argues that morality should be treated as a legitimate object of study for anthropologists and analyzed in its political contexts. From this perspective, his work has been concerned with the “politics of compassion,” namely, the various ways in which inequality has been redefined as “suffering,” violence reformulated as “trauma,” and military interventions qualified as “humanitarian.”


Cite this:

Fassin, Dider.  2009 Illegal Immigrants as the Last Frontier of Welfare. AccessDenied: A Conversation on Un/authorized Im/migration and Health. Accessed (date) at https://accessdeniedblog.wordpress.com/2009/12/02/illegal-immigrants-as-the-last-frontier-of-welfare/

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