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Bioethics Forum Essay

How “America First” Undermines Our Health

People value their health. It allows them to pursue their aims and enjoy their lives, and it contributes to their well-being. But health is not only good for particular healthy individuals. It is also good for their families, communities, nations, and in a world in which people flows are global, health is good for the global community. Health fosters robust economies and fruitful innovation. It has a spillover effect. Because people are socially embedded, it is difficult to exclude others from the good and bad health of individuals. This can be clearly seen with respect to contagious diseases, and with vaccinations and herd immunity. If enough people have been vaccinated, the immunity provided by the vaccination is conferred on people who have not been vaccinated. In the absence of social isolation, the benefits (and harms) of health extend to others. Not only does one person’s health not deprive others of health, it very often contributes to the health of others.

Put differently, our health depends on the health of others. The social determinants of health provide another good example of how health depends upon other people. Inequality, for example, harms the health of rich and poor, though the poor are more vulnerable. Studies also show that social networks are important for health. For example, the likelihood that a person will be obese increases when their social networks include many obese people. A similar phenomenon has been observed with depression. Social determinants of health, such as inequality and our social networks, are critical for health. Indeed, some studies show that the social determinants are more important for health than medical care. Because people are social and thrive in the company of others, it is difficult, if not impossible, to limit their exposure to the health of other people. As it turns out, loneliness and social isolation are also risk factors for health. So even if one could limit one’s exposure to the social underpinnings of health, it would be counterproductive to do so.

Economists call goods with these characteristics public goods. Public goods are nonrivalrous and nonexcludable. Fireworks are a good example. One person’s enjoyment of fireworks does not interfere with the enjoyment by others. Indeed, collective enjoyment might enhance the experience. It would also be difficult, if not impossible, to exclude people from enjoying them.

Because it is difficult to exclude people from enjoying public goods, people may try to enjoy the good without contributing to it—so-called free riders. In our new book, The Health of Newcomers, Wendy Parmet and I suggest that health understood as a public good should guide health care policy for immigrants. Many nations, including the United States, refuse to provide health care to immigrants, both documented and undocumented. When health is understood as a public good, we can see the inherent irrationality of such policies. The health of natives depends upon the health of immigrants, and, in turn, the health of immigrants on the health of natives. It is therefore in everyone’s interest to ensure the health of others—regardless of whether they are native or newcomer.

Understanding the public good dimension of health can also alert us to the moral risk that arises when we refuse to provide newcomers with health insurance. Newcomers tend to be younger and healthier than natives. When natives refuse to protect the health of newcomers, but nonetheless enjoy the health benefits that newcomers bring, natives are free riding, and thereby violating basic principles of justice and fairness.

When it comes to health, it is in our interest to promote the health of all people—distant strangers, natives, and newcomers. In view of health’s public good dimension, an America-first perspective toward health will simply not work.

A wall could be built, and strangers could be kept out, but as long as there are people crossing national borders for business, tourism, and family, the diseases of people in other countries will have an impact worldwide, and so too will our health impact theirs. Similarly, given the public good nature of health, it is very much in the interest of the United States to ensure that newcomers, neighbors, and the global community are as healthy as possible. When the health of others suffers, so too will our health. When the health of others flourishes, so too will ours. Health has the potential to bridge differences and underscore our common humanity.

Patricia Illingworth, J.D., Ph.D., is a research fellow at the Carr Center for Human Rights, Kennedy School of Government, Harvard University, and a professor at Northeastern University. She is the author, with Wendy E. Parmet, of The Health of Newcomers: Immigration, Health Policy, and the Case for Global Solidarity, published in January.

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  1. I think it is questionable to assert that the health benefits that immigrants bring to our country are so significant that we are free riding on their contribution. From my perspective, when they first arrive and have yet had an opportunity to contribute to our medical revenues, that they are the free riders.

    And it further needs to be acknowledged that health care does not have an unlimited call on the financial resources of this country. While one may argue that they are misallocated, no one can assert that they are unlimited.

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