Bioethics Forum Essay

Immigrants, Health Inequities, and Social Citizenship in Covid-19 Response and Recovery

The novel coronavirus pandemic has starkly revealed the vulnerabilities of low-wage immigrants, immigrant-led households, and immigrant communities to coronavirus infection, severe Covid-19 illness, and economic fallout from pandemic. This public health emergency compounds pre-existing social inequalities and resulting health inequities associated with immigrant status and immigration policy priorities. Structural barriers to health care access and utilization have consequences for health and well-being and for citizen children in mixed-status families.

For undocumented immigrants in the United States, structural barriers to health care access and utilization include exclusion from federally funded health insurance programs and other health-related programs, such as housing subsidies and food stamps, plus the consequences of immigration enforcement. Undocumented immigrants fear encounters with perceived authorities that could lead to detention, deportation, or family separation.

For legally present immigrants in the U.S., structural barriers to health care access and utilization include the chilling effects of the public charge rule, which jeopardizes eligibility for legal permanent residency (green card) if applicants are deemed “public charges” based on even short-term use of federally funded health-related programs. These immigrants remain eligible for but fearful of using these programs.

Data on Covid-19 risk factors, infections, hospitalizations, and death rates reaffirms the observation of Nancy Krieger, a professor of social epidemiology at Harvard,  that inequalities created and tolerated by a society are embodied in health inequities experienced by marginalized populations, such as immigrants, minorities, and low-wage workers. In New York City, Latinos represent 29% of the population and 34% of Covid-19 deaths. This dismal statistic reflects the barriers to health care access and utilization described above, plus the environmental effects of concentrated poverty and precarious working conditions. Immigrant neighborhoods in central Queens include tens of thousands of apartments that are noncompliant with zoning and building codes and are rented to low-wage immigrants with few options for housing. These crowded, poorly ventilated apartments, often in basements, create ideal conditions for contagion. In Singapore, the second wave of infections is concentrated in dormitories for migrant workers. In Sweden, disproportionately high Covid-19 infection among immigrant communities have raised questions about the effectiveness of public health messages.

Immigrants and other members of New York City’s low-wage workforce continue to use mass transportation to commute to hourly-wage jobs that cannot be done from home. Analysis from the Migration Policy Institute shows that immigrants are essential workers in pandemic response in the U.S. because many work in health care, including operational and frontline roles, and in all areas of food supply, from agriculture to grocery stores. Other immigrants who have lost jobs in fields outside of health care and other “essential” businesses may have limited or no access to unemployment benefits or federal relief aid. Domestic workers, most of whom are immigrants and women of color, may have limited access to information and resources for Covid-19 worker protections.

In the U. S. and worldwide, most immigrants and internal migrants live in cities and greater metropolitan areas, creating neighborhoods and contributing to economic, social, and cultural activity at all levels. In this evolving public health crisis and its long recovery, recognizing immigrants as social citizens of the places where immigrants live and work and mitigating their embodied vulnerabilities should be integral to public health ethics.

To support learning and response, The Hastings Center has created a Covid-19 resource on immigrant health.

Nancy Berlinger is a research scholar at The Hastings Center and the cofounder of the Center’s Undocumented Patients project. She is the first author of The Hastings Center’s Ethical Framework for Healthcare Institutions Responding to Covid-19 and of related training tools for institutional ethics services.