Southern Medical Journal:
Public Health & Environmental Medicine
Aponte-Rivera, Vivianne R. MD; Dunlop, Boadie W. MD
From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.
V.A.-R.: no financial relationships to disclose and no conflicts of interest to report. B.W.D: Principal Investigator and research funds from Evotec, Forest, Novartis, and Pfizer; Investigator and research funds from AstraZeneca; consulting honoraria from MedAvante.
Accepted July 6, 2011.
Reprint requests to Vivianne R. Aponte-Rivera, MD, 1256 Briarcliff Road NE, Building A, 3rd Floor Suite 306E, Atlanta, GA 30306. Email: firstname.lastname@example.org
Georgia's House Bill 87 (HB 87), called the "Illegal Immigration Reform and Enforcement Act of 2011" took effect on July 1, 2011. This law was modeled after Arizona's controversial immigration law Senate Bill 1070 (SB 1070). Thirty-six other states are considering similar bills.1 While there is ongoing debate about the constitutionality of the Arizona and Georgia laws, there has been little consideration of the potentially detrimental effects the laws would have on the overall health of the public and of immigrants in particular.
A temporary injunction recently was issued for certain aspects of HB 87, but these laws continue to be of significant concern until a definitive ruling is made. HB 87 targets individuals who might be considered as helping an illegal alien avoid detection by authorities by considering it a misdemeanor punishable by imprisonment and/or a $1000 fine. Punishable actions include "harboring", which is broadly defined as "any conduct that tends to substantially help an illegal alien to remain in the United States (US)."2 The law specifically exempts "a person providing emergency medical service,"2 which appears to leave non-emergency medical providers open to prosecution.
Whether or not state enforcement agencies choose to prosecute physicians under this law is not directly relevant to its potential public health consequences. The primary public health risk arising from these laws is that both legal and illegal immigrants may perceive seeking clinical services as too risky. HB 87 stipulates that a person can be charged with transporting an illegal alien if he or she "while committing another criminal offense, knowingly and intentionally transports and moves an illegal alien in a motor vehicle for the purpose of furthering the illegal presence of the alien in the US."2 The vague language of the law will create uncertainty for individuals or groups (e.g. churches) that drive immigrants to appointments. Thus, even if they do not fear being reported by physicians, illegal immigrants can face detention and their legally residing relatives and friends can face prosecution if they are detained by police while in transit.
Enforcement of these new laws can be predicted to harm the public's health in three meaningful ways. First, there will be a reduction in prevention of illnesses among immigrants, particularly those residing illegally in the United States. By increasing the risks for attending a clinic, many patients will choose to forgo medical visits, with the predictable consequences of greater morbidity and mortality among immigrant populations and potentially impacting other non immigrant proximate populations. Specific potential harms include delayed treatment for communicable diseases, reduced vaccination rates, and higher rates of unwanted pregnancy and sexually transmitted infections. Furthermore, reduced care for serious psychiatric illnesses would result in greater rates of suicide, substance abuse, and psychotic episodes and raise associated societal harms. Due to the extensive intermixing of cultural groups within the United States, the consequences of these effects, although initially affecting illegal immigrants, will inevitably affect the health of legal immigrants, and ultimately the broader population.
Second, it seems likely that a sizeable proportion of illegal immigrants, and their legally residing family members, will relocate to other states. In this regard, Arizona represents a test case for state-level immigration reform. It has been estimated that 100,000 Mexicans left Arizona in the three months following the passage of law SB1070, with only 23,380 of those returning to Mexico.3 The resulting influx of poor and uninsured immigrants to neighboring states will increase the demands on public health services in those states, resulting in longer wait times and reduced availability for those residents already using these services. Thus, state-level implementation of immigration reform will produce a shifting of the public health burden from one state to the next, which will only intensify as more states pursue laws that replicate SB1070 and HB87. With each additional state that adopts an Arizona-style law, the pressure on other states to do so increases.
The third consequence of these laws will be an increase in the number of patients receiving treatment in illegal healthcare settings. Although little known outside the immigrant communities, illegal clinics have increasingly become a viable and trusted source of medical care for immigrants residing in the United States. Staffed by unlicensed doctors, nurses or dentists trained outside the United States, these clinics often operate out of private homes. Providers within these clinics perform procedures and dispense prescription medications smuggled from other countries. Predictable consequences from these practices are greater antibiotic resistance and adverse health outcomes due to iatrogenic actions, drug interactions, and delayed receipt of appropriate treatment. Here again, the consequences of increasing barriers to accessing health care for illegal immigrants will serve to undermine the health of all residents, due to increased demand on emergency responders and threats to the efficacy and quality of the pharmaceutical armamentarium. Going forward, efforts should be made to measure the impact of changes in immigration law on the public health outcomes discussed above.
Concerns about the fiscal costs to the states stemming from illegal immigration appear to be a primary driver of these laws.4 This view may turn out to be short-sighted, as the public health costs arising from hindering access to care for illegal immigrants accumulate. Defensive state-by-state approaches to immigration reform are inadequate. Only a federal approach can prevent the public health cost shifting and deleterious effects on health. Recognizing that there are consequences for all Americans arising from these laws may serve as a point of clarity in the debate and contribute to a more viable solution to the problem of illegal immigration.