Borders, centers, and margins: critical landscapes for migrant health.

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Advances in Nursing Science Vol. 37, No. 3, pp. 197–212 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Borders, Centers, and Margins Critical Landscapes for Migrant Health Sharon McGuire, OP, PhD, FNP-BC, CTN-A, FAANP Nurses in North America have a distinguished history of involvement in immigrant health due to the immigrant character of this region. The Western Hemisphere is a region composed of recent migrants from nearly every corner of the globe. Complicated economic, environmental, and social dynamics contribute to these various migration patterns and commensurate healthrelated issues—physical, psychological, and spiritual. Nurses attuned to health issues of newer immigrants’ lives use newfound knowledge to shape the care they provide, and political advocacy. This article updates our understandings of migration, utilizing critical perspectives to analyze contemporary dynamics of migration and respective health issues. Key words: borders, detention and deportation, immigrant health, immigrants, immigration reform, marginalization, migrant health, neoliberalism, prisons, undocumented immigrants

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ARDLY HAS any issue in society prompted such heated political disputes as that of immigration, not only in North America but also in the European Union (EU), Israel, and other countries. Rarely, however, are the major forces that compel people to migrate acknowledged or discussed, thus obscuring the landscapes that inform migration and its social, political, and health contingencies. This article, then, is about landscapes and migration, and how these landscapes influence the lives and health of migrants and immigrants. Because of their most vulnerable status, this article will particularly but not exclusively attend to situations of undocu-

Author Affiliation: Walden University, Minneapolis, Minnesota; and Adrian Dominican Sisters, Adrian, Michigan. The author thanks Drs Joyceen Boyle and Dorothy Kleffel for their review of the original manuscript The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Sharon McGuire, OP, PhD, FNP-BC, CTN-A, FAANP, 16141 Malaga Ln. Apt A, Huntington Beach, CA 92647 ([email protected]). DOI: 10.1097/ANS.0000000000000030

mented immigrants or unauthorized/irregular migrants as they are known in Europe. Various landscapes comprise the backdrop of the world’s migrant population and exert profound influences on the great demographic shifts peculiar to migration. These landscapes will include historical colonialism, neoliberalism or the new colonialism, undocumentedness, detention centers and deportation, and the migrant journey. The use of the term “landscapes” has appeared in scholarly literature in education, nursing, architecture, digital communication, literature, and other disciplines to signify a broad way of looking at a phenomenon from a point of view.1 Etymologically, “landscape” is a term originated around 1600 and refers to painting an expansive scene, so it has geographic connotations. Finally, it can refer to “an extensive mental view, an interior prospect.”2 A deepened understanding of landscapes can inspire emancipatory nursing praxes such as advocating for migrant/immigrant communities in health care settings and in neighborhoods; supporting the US Dream Act (the legislation that would provide a path to citizenship to those undocumented youth who wish to pursue higher education or who serve in the US military); or advocating for meaningful immigration reform. These suggestions are 197

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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examples and by no means limit emancipatory nursing enterprises with immigrants. Migration scholars recognize and attempt to increase awareness that one of the most critical issues of the 21st century is migration, and hence its salience to nurses who care for migrants and immigrants in numerous health care settings. Globally, 214 million people live outside the country of their natal origin, or 1 of every 33 people on Earth.3 Of the 40 million first-generation immigrants in the United States, 11.5 million are undocumented.4 Nurse scholars like Meleis et al,5 Lipson and Miller,6 Lipson and Omidian,7 and Messias8 to name a few have uncovered links between migrancy and health, but this field is ripe for further nursing research. Because Latino undocumented immigrants from Mexico, Central America, and the Caribbean countries comprise almost three fourth of the undocumented population in the United States, they will be the primary focus of this article.9 According to the Chile-based Latin American Center of Demography, fully half of international migrants are women who, because of their greater vulnerability to assault, face the double risk of being female and migrant. While these global demographics make obvious the presence of immigrants in most places where nurses practice, it is the personal, familial, and community encounters with migrants that begin to put a human face on the reality of newcomers and their lives. Given that in the United States there are more than 40 million immigrants, or that 1 in every 8 persons is an immigrant, nurses can hardly avoid caring for a few or for many in clinical settings and some nurses themselves are immigrants.9 Female migrants, both because of their increased risk of health-related phenomena and their roles as guardians of children’s and family health will most likely be those that nurses find in practice, although not exclusively as women are often the inspiration for their male spouses or partners to seek health care. Within this practice reality then, and the larger social reality that serves as context, migration poses consider-

able challenges to nursing practice, research, education, and policy making. This article purports to engage various critical perspectives in examining some pertinent landscapes and the increasingly complex patterns and issues inherent in migration and health. In this case, the use of critical perspectives implies unearthing less visible; deliberately hidden; or ignored social, political, economic, and environmental landscapes that influence migration phenomena and consequent health issues. Using critical perspectives enables us to peer through dominant narratives to bring hidden realities and experiences of socially, politically, and economically marginalized people into focus. These perspectives challenge what we know or think is truth and facilitate the surfacing of truths that have been suppressed or concealed. Those critical perspectives deployed in this article are primarily critical social theory, postcolonialism, and critical theological perspectives that unearth the deep humanity of migrants. More recent scholarship has also used transnationalism as a crucial analytical tool when examining emerging contemporary patterns of migration.10 These perspectives also share an emancipatory purpose in that their purpose is to turn dominant oppressive views on their head; build liberating awareness and knowledges; and encourage struggles for justice, solidarity, and respect. Transnationalism in this context shares these emancipatory purposes in that many of today’s immigrant communities maintain communication patterns and cultural practices from their home countries, thus resisting complete assimilation by a dominant culture, and forming bases for collective action against oppression. A historical macro view of migration, born from these perspectives, sheds light on current migratory patterns, especially in Western countries with their discursive constructs of immigrants of color or differing ethnic origins. This view also informs current worldwide political debates, deliberately constructed structural barriers to migration, and virulent anti-immigrant rhetoric, methods of


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Borders, Centers, and Margins producing marginalization.11 This article links the diffusion of neoliberal economic policies with unemployment, displacement, and migration. Varsanyi and Nevins12 point out the contradictions in these neoliberal policies that encourage migration while closing off borders, thereby giving rise to unauthorized migration across borders. An expanded view of the predicament and nature of undocumentedness might help nurses and other health workers resist negative imagery, antiimmigrant rhetoric, and promote rational positive imagery and speech in their place. I begin by examining the landscape of undocumentedness, because of its urgency as a salient site of action for emancipatory nursing and health care practices, followed by the other landscapes identified earlier in the article. An identification and discussion of health issues embedded in migrancy, especially unauthorized migrancy, as sites for emancipatory nursing praxis follows an examination of the landscapes.

LANDSCAPE OF UNDOCUMENTEDNESS Whether referred to as undocumented, irregular, or unauthorized the terms “illegal” and “alien” are pejorative and originate in nativism, an anti-immigrant attitude rooted in self-interest and maintenance of the status quo. Unfortunately, these pejorative terms are in common usage in media outlets in the United States. They are terms that have provoked both “right and left,” the former because it connotes criminality and the latter because the term is dehumanizing. White/European origin undocumented immigrants seem to be protected from the social and political effects of the terms and often can find work in the United States without a visa; the community most adversely affected is the Latino population.13 The term “illegal” seems to be conjoined with myths perpetuated about immigrants without authorization to be in a host country, myths that construct the undocumented immigrant as a burden on the country when quite the contrary is

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true. Undocumented immigrants contribute approximately 7 billion dollars annually to the Social Security fund and pay Federal, State, and local taxes just as most working citizens do.14 The terms “illegal” and “alien” should be avoided in nursing discourse and the professional literature to show respect for the undocumented immigrant as a human being. Ontology of undocumentedness Messias15 was the first nurse scholar to identify undocumentedness as a pertinent concept appropriate for the domain of nursing, and needing further nursing elaboration. In the sparse literature, including nursing literature extant at the time she found that undocumented immigrants suffered from fear, restricted mobility and access, that they were uncounted and unnoticed, were vulnerable and exploited, were subject to discrimination and often blamed for society’s ills. Messias15 also found that the proportion of undocumented immigrants was increasing, commensurate with contemporary findings in the 21st century. Undocumentedness is a juridical status, not a crime, which defines the relationship of the undocumented immigrant to the state.16 There is nothing inherently “illegal” in any human being; that is, there is not a genetic predisposition toward “illegality.” Rather it is a socially, politically, and legally constructed status by way of discourse and legislation that confers the liminal condition of undocumentedness. This social construction of undocumentedness may be conceived as a form of violence to the immigrant because of the trauma, marginalization, and hardships it produces. Health risks of undocumented status Being an undocumented immigrant is in itself a health hazard. Even if undocumented immigrants are healthy when they enter the US, their health begins to deteriorate over time due to their economic, cultural, and political marginalization. The border crossing


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may have been a traumatic experience, fraught as it is with dangers from thieves, rapists, murderers, terrain, wild animals, weather patterns, and the risk of dehydration or of freezing to death, and a militarized border, especially for women migrants. In addition to the trauma, rape makes women especially vulnerable to the risk of sexually transmitted infections, including human immunodeficiency virus and hepatitis C. Those who travel by sea, for example from Haiti or from Africa to Europe, brave the hazard of uncertain seas in overcrowded boats, or of immediate detection and deportation by ICE (Immigration and Customs Enforcement) or by its European counterpart patrolling the waters off the coast of Spain.17 Many migrants have lost their lives on treacherous seas in these boats. Among the complex patterns of migration are those related to a history of colonialism—for example, from the Caribbean to England, from some African countries to France and Italy, from the Philippines to the US Migration on a global scale began with the period of European colonialism.18

LANDSCAPE OF COLONIALISM Anthropological studies point to migration as a normal human activity. Migration is evidenced in human history, given what we know to date about the origins of humanity and its gradual dispersal over the Earth. Although migration is a long standing human activity, the scope, scale, and rate of increase of migration was negligible in ancient times and in the Middle Ages. The period of European colonial history initiated migration on a global scale beginning in the 15th century. The explorations of Christopher Columbus, an Italian sailor adventurer sponsored by Queen Isabella of Spain, led him and his Spanish sailing crew from Seville, Spain, to the Western Hemisphere. They landed on the island now known as the Dominican Republic and Haiti, calling it Hispaniola. Welcomed by the indigenous Taino Indians, the Spanish ad-

venturers and Columbus saw opportunity for territorial riches and the exploitation of Indian labor. The Spanish newcomers betrayed the hospitality of the Tainos, slaughtered or enslaved them, and expropriated their lands. These early colonizing and expropriating activities in Hispaniola set off several centuries of similar activities by Great Britain, Western and Northern European countries colonizing much of the non-European world. Included among these countries and Continents were most of the Western Hemisphere, most of the African Continent, the Middle East, Southeast Asia and China, Australia, and other Islands of the Pacific and the Caribbean. The history of European colonization is complex, nonmonolithic, but fairly ubiquitous in that colonizing countries, dismantling the territories of indigenes, established new nation states with new and sometimes shifting borders, and colonial economic systems facilitated by the destruction of indigenous economies, or self-supporting systems including, for example, cottage industries, indigenous trading cultures, and agricultural practices.19 Colonization disenfranchised many indigenous populations who appeared “different” from Europeans in body morphology, skin hues, languages, cultural practices, and social and self-governance/political structures. Many died from enslavement by the colonizers, outright slaughter and burnings, and European microbial diseases to which they were not immune.20,21 The colonial era, in sum, involved millions of White Europeans migrating to non-European world regions and creating the concept of nation states with their carefully constructed land and water borders.22 It also meant new and devastating diseases to which there were no apparent remedies. During this time also, millions of captive Africans found themselves in some of these newly colonized lands as slaves to white owners in the newly formed colonies of the United States and Central and South America. These Western Hemispheric colonies eventually won their independence, and slavery as a legitimated institution


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Borders, Centers, and Margins was abolished. Today the African diaspora, African immigrants and their descendants, is worldwide, and health disparities of those people are associated with the stresses of racism among other influences.23 Ultimately, political, economic, and cultural ties bound many colonized countries to the colonizer countries that presaged a “reverse migration.” Almost commensurately, the contentious field of postcolonial studies was born. Edward Said,24 a Palestinian born scholar, activist, and Professor of English Literature and Comparative Studies at Columbia University, published one of the earliest works ushering in postcolonial scholarship. His work and seminal book, Orientalism, addressed the British/Western representation of Middle and Near Easterners, colonized peoples as inferior, exotic, as the Other who is to be reviled for their difference while envied for their colonist-perceived erotic exoticism. Nurse scholars have advocated for the use of postcolonial paradigms in nursing research because of its attention to race, cultural conceptions, and racialization processes, especially with immigrants and indigenes. Anderson et al25 have all conducted research using critical feminist postcolonialism as both paradigm and method. These nurse scholars have explored notions of race and racialization among both immigrants of color and Canadian born persons of European heritage in health care settings in Western Canada. Among their conclusions, they advocate to make social suffering and health inequities more explicit to advance an agenda of social justice in health care. Recent historical background Decolonizing struggles of countries of the African, Asian, and Latin American continents, and Islands in the Caribbean and Pacific in the 19th and 20th century gave rise to new migration patterns across the globe. European and British colonial powers, having established economic, political, and cultural ties with their colonies now became destinations for migrants from former colonies. The United

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States, with its own colonial history in the Philippines from 1898 to World War II, its labor recruitment of Chinese to build railroads, and of Mexicans for agriculture, also became a magnet for migrants from those countries and other countries from around the world. With shifting social, economic, cultural, and political landscapes over the last 3 decades, we have witnessed new intricacies in migration patterns that bear witness to the contested terrain of postcolonial studies. Today, patterns of migration are increasingly varied and complex. How do Vietnamese immigrants find Czechoslovakia or Norway? How do single Iranian mothers and children find Canada? Wars, regional conflicts, political dangers, and economics have sent Bosnian refugees to the United Kingdom and the Netherlands; Croatians to Sweden; Palestinians to Lebanon; Moroccan women to Italy; Iraqis to France, Germany, and the United States; Sudanese refugees to Egypt; and Western African refugees to Western Australia, to name a few.26 Although these questions have yet to be answered, nurse researchers could address these dynamics, and discover aspects of migrants’ agency, as part of the context for their research. Scholars of migration note also that in the last 2 to 3 decades many transnational migrants have maintained strong ties to their homeland while incorporating themselves into the new society, or consider themselves as members of “transnational communities,”26(p1) that is, communities in their homeland and communities in their host country. Communication technologies and modern modes of transportation facilitate these newest patterns and sustain binational relationships, often tied to notions of home and liminality.19,26 The majority of transnational migrants move to Western Europe, the Middle East, or North America. Almost two-thirds of cross-border migrants relocate to Western Europe and North America; the majority of remaining migrants live in Middle Eastern countries—such as Bahrain, Jordan, Kuwait, Saudi Arabia, Japan,


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Australia, and United Arab Emirates—and in Asian countries.27 These destinations follow both a postcolonial history and newer sociopolitical, economic, and environmental influences, one of significance being neoliberalism, in the United States more known as neoconservatism. Hence, these terms will be used interchangeably in this article. It is ever more urgent to uncover the relationship between neoliberalism and migration to move nursing toward greater emancipatory practice with those immigrant populations who suffer from poverty, discrimination, and injustices in health care and in the larger society. Parenthetically, a deepened understanding of neoliberalism’s influence on health care systems and population health is most germane to nursing organizations, nurses, and health policy makers.28

THE LANDSCAPE OF NEOLIBERALISM/ NEOCONSERVATISM: A NEW COLONIALISM Squires,28 in her review of Vincent Navarro’s book on Globalization, and Inequalities: Consequences for Health and Quality of Life, argues that a study of neoliberalism is incumbent on the nursing profession. A deepened understanding of neoliberalism as the dominant economic policy in most of the world amplifies our insights into the social determinants of health, and further rounds out our views on migration by seeing connections between neoliberalism, migration, and health inequities. Serendipitously, another benefit to nursing in pursuing this deepened understanding of the world’s dominant economic model and its tenets as they are currently operationalized was expressed recently in Maria del Pilar Carmargo Plazas’s29 study of health care and chronic illness in Columbia in a neoliberalism health care system. In this phenomenological study, she illustrates the difficulty of securing appropriate health care for chronic illness even when insured. Analogies could be made in the United States when people are denied treatments they need, even

when insured, until the Patient Protection and Affordable Care Act (PPACA or ACA, sometimes called “Obamacare”) of 2009 takes full effect in 2014. Although the PPACA does not eschew neoliberal health care in the United States, it does erode its power and returns health care more toward a social compact and human right. For nursing in general, in addition to the cultural competence that has become an expectation, social justice-oriented praxis may take a number of forms. One of the newest forms of colonialism to appear has been the advent and implementation, often using violent methods, of neoliberal/neoconservative economics. The triad of deregulation, privatization, and corresponding reduction in social spending constitute the central tenets and ideology of neoliberalism/neoconservatism. These tenets drove American capitalism until the Great Depression of 1929 (a driver of massive internal migration), which spurred state regulatory environments, and increased social spending to curtail the excesses of capitalism, affording some protections to the public in Roosevelt’s New Deal.30 During this era, the notion of the common good took hold and prevailed until the 1980s era of Reagan in the United States, Thatcher in Great Britain, and Mulroney in Canada.31 Nursing literature has alluded to neoliberalism32 but has not elaborated its historical, theoretical, or moral underpinnings, or how it has been operationalized in so many parts of the world, including nursing practice in hospital corporations. Thus the “values” perhaps of doing more with less, and eroding the art and autonomy of nursing, for example, by creating “scripts” nurses must follow in communicating with patients, have become intrinsic to everyday nursing practice.33 Although rooted historically in the Mercantilism of The Dark and The Middle Ages, and articulated later in Adam Smith’s book The Wealth of Nations,18 its newest guru was Milton Friedman,34 head of the University of Chicago’s economics department. His theories on economics and “free markets” have wielded enormous influence on the


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Borders, Centers, and Margins diffusion of neoliberal economic models and policies around the world. Although this article cannot possibly elaborate on the full implications of neoliberalism and its effect on populations of people forced to migrate either internally or transnationally, it links the diffusion of neoliberal economic policies with unemployment, displacement, and migration. Examples include Chile, one of the first countries to adopt neoliberal economics as a consequence of the Pinochet coup that toppled democratically elected Salvador Allende in 1973, and other countries like Argentina, Bolivia, Poland, Russia, South Africa (political apartheid ended but not economic apartheid), China, and other Asian countries. These countries have seen large internal migrations from rural to urban areas, and transnational migration of their citizens.30 Neoliberal policies have also influenced transnational migration, including international nurse migration.28 Neoliberalism eschews ideas of the common good and community35 as a threat to its mantra of “personal responsibility” and its practices of privatization. It ignores attention to the social determinants of health embedded in neoliberal policies and foists the entire responsibility for health onto people who occupy differing social strata with unequal access to resources for health, including healthy working environments, healthy neighborhoods, affordable health care access, and other beneficial health contingencies.36 Given that certain immigrants to the United States suffer from poverty and marginalization in society, undocumented immigrants in the United States in particular have either reduced access to health care or are excluded from all but emergency department access to care. They have been excluded from the PPACA of 2009. Even documented immigrants who have been here for fewer than 5 years have been excluded from such programs as Medicaid with the exception of the Children’s Health Insurance Reauthorization Act (CHIPRA) passed in 2009. However, only 20 states as of December 2012 had taken advantage of CHIPRA Federal dollars

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to cover authorized children and pregnant women.32 Instruments of neoliberal policies have been the World Bank, the International Monetary Fund, the World Trade Organization, and “free trade” agreements such as the North American Free Trade Agreement, the Dominican Republic-Central American Free Trade Agreement, and numerous agreements with other countries such as Korea and Australia. As a condition for international loans from the World Bank and the International Monetary Fund, countries have had to privatize public services, public land, and other resources owned by the public.19,37 These agreements technically eliminate tariffs, reduce barriers to services (like nursing), and open markets. A major problem between countries that are unequal in economic strength, for example, is that the United States has dumped corn onto Mexico, effectively destroying Mexico’s traditional self-sufficiency in corn production. This new dependency on the US corn has destroyed the livelihoods of 1 million Mexican peasant farmers who had been engaged in subsistence farming, creating a vast new pool of migrants.38 This example is but one showing how neoliberal policies, implemented around the world, have produced unprecedented new migrants, many undocumented or irregular/unauthorized crossing international borders.12 One of the methods arising from colonial perspectives and neoconservative ideology for dealing with undocumented immigrants is detention and deportation.

LANDSCAPE OF DETENTION AND DEPORTATION Since 1996, the inflexible and punitive detention and deportation policies of the Illegal Immigration Reform and Immigrant Responsibility Act have been implemented. These policies do not take into account any context of a migrant’s life, and immigration judges’ hands are tied by the statutes so they cannot exercise independent judgment.39 As Drevdahl and


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Dorcy40 assert these policies are fundamentally unfair and target poor “unskilled” workers who are usually employed in low paying jobs. If an undocumented migrant is detected even after having been settled and employed for many years, they continue to face possible detention and deportation. These migrants are often separated from their families, spouses, and children, causing family separation and grief for all. Similar scenarios are unfolding in the EU, which had 224 detention centers, 23 of them in France, as of 2008.41 In the United States, some children are now in foster care because their parents were deported and they, having been born here, are citizens or simply were not apprehended and sent with their parents in spite of citizenship. For example, within the first 6 months of 2011, 46 000 undocumented parents of citizen children were deported. Altogether, 100 000 children in the United States have experienced the deportation of one or both parents (Personal communication, Frank Sharp, Executive Director, America’s Voice, December 4, 2012). According the Applied Research Center of Colorlines.com, a 30year-old think tank to promote racial justice, 5100 citizen children of deportees were in foster care throughout the country by 2007. These are Federal figures obtained by Applied Research Center through the Freedom of Information Act.42 Mental and emotional health implications of such draconian rigid policies, both for children separated from parents, for parents deported without their children, and for a spouse left behind when the other one was deported are of concern to an emancipatory nursing praxis with its potential to influence immigration policy through research, practice, advocacy, and solidarity with immigrants’ rights organizations. Not to be forgotten are the many legal permanent residents and naturalized citizens who have been and continue to be detained and deported for sometimes decades old misdemeanors for which they have already paid.39 Human Rights Watch39 cites the case of Antonio Cerami, who came with his family from Italy as a lawful permanent resident

at the age of 12 years. He eventually became employed, married, and helped raise 4 of his wife’s children and 1 of their own. He brought his youngest son and wife to Italy for a niece’s wedding. Upon his return, he was accosted by immigration agents at O’Hare airport, for a 19year-old nonviolent conviction for which he had paid restitution, and deported to Italy. His family lost everything, including their house; the children are living with relatives while his wife recovers from the trauma and can care for the children economically and emotionally. The youngest son has already turned to drugs. In a country where the rhetoric has often been on “family values” or that ought to value families, this scenario signifies contradictions in laws and law enforcement practices that destroy family cohesion and lives. These policies create health problems, burden family members, harass immigrant communities, and cause unnecessary suffering. Moreover, according to Human Rights Watch, The US Supreme Court has upheld “the right to live together as a family,” calling it in 1977 an “enduring American tradition,” while noting that the right to raise one’s child has been deemed a basic civil right, one “far more precious than property rights.”39(p58) The United Nations’ Universal Declaration of Human Rights asserts a fundamental right to find a family, and to live together with close family members, including minor children.39 Clearly current detention and deportation policies have been instituted that disregard these rights and violate the intent and spirit of these principles enunciated by the US Supreme court and the United Nations. For-profit detention centers In the United States, for-profit prisons and detention centers began business in 1983 in the privatization boom of early neoliberalism ushered in by President Reagan. Correctional Corporation of America (CCA) was an early pioneer in the privatization of prison systems, and now it imprisons approximately 80 000 inmates in 16 states, Puerto Rico, and the


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Borders, Centers, and Margins Virgin Islands.43 The GEO (not an acronym) group, and some smaller for-profit prison systems, also house thousands of inmates. Seeing an opportunity for profitability CCA linked up with ICE to detain undocumented immigrants. Because revenue was coming from the Federal Government at rates from $79.00 to $140 per detainee per day, rather than the state at $18.00 per prisoner per day, the deal was not only sweet for them, but it enticed them to promote the harsh legislation, SB 1070, passed first in Arizona. More detainees (a euphemism because they are really treated as prisoners in cells) mean more profits, and of the inmates in the private prison industry more than 50% are undocumented immigrants (Personal Communication, Rev Les Schmidt, July 15, 2012). Thus SB 1070, recently struck down by the Supreme Court but for the worst provision still authorizes police to ask “suspected” undocumented immigrants for their papers, a practice that has led to incidents of racial profiling of people of color, including citizens and authorized immigrants (United States Conference of Catholic Bishops Immigration Conference, December 3-5, 2012) Correctional Corporation of America is a member of the American Legislative Exchange Council (ALEC), a right wing corporate and foundation-funded organization that writes and promotes such laws as “voter ID,” laws geared toward stripping special education students of due process rights and rights to services, and the anti-immigrant laws now in place, besides Arizona, in Georgia, Alabama, and South Carolina. Members of ALEC are large corporations like Exxon Mobil, Koch Industries etc, and conservative state legislators to whom the bills are handed at ALEC’s conferences. The legislators pay $50.00 per year in dues, so 99% of ALEC’s funding is corporate. Because ALEC was exposed lately by a collaborative effort of the Center for Media and Democracy and the Nation magazine in its series of articles, 25 corporations and 54 legislators have withdrawn from ALEC.44 But many more remain, including CCA. Exposing the powers and moneyed interests of CCA,

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the GEO group and other private prison industry groups and their moneyed interests in the detention and deportation of immigrants ought to be enlightening and of great interest to professional nursing, because it provides one of many foci for nursing’s political activity. Given that ALEC also works to undermine the PPACA, to protect the interests of the insurance industry, big Pharma, and to undermine patients’ rights44 is only added impetus for nursing to find and expose state legislator members of ALEC to colleagues and to the health care community. Thus the private prison and detention industry enriches its bottom line through the incarceration of many thousands of hard working human beings who happen to be here without authorization, and who have no criminal record. Nurse advocacy, such as educating and talking to legislators and their staff about shattered families because of policies of detention and deportation, is powerful. Identifying legislators with ties to ALEC is another way nurses can engage in emancipatory praxis. SPIRITUALITY AS A LANDSCAPE OF THE MIGRANT JOURNEY Many persons practice some kind of spirituality, whether yoga, meditation, contemplation of natural beauty, or other activity that reflects a search for meaning. I speak from this premise, and the circumscribed position of my own adherence to Catholic Social Thought, a school of thought emerging in the late 19th century that put the Catholic Church squarely on the side of labor in struggles for social justice. Critical theology is akin to liberation theology and critical pedagogy, and it is similar in its aims to emancipatory nursing.45 All these views challenge domination by oppressive powers in society, in health systems, in workplaces, wherever centers of power keep others down and marginalized. That is, similarities among these frameworks are founded on their critical outlook on marginalizing and oppressive systems, on discourses that stereotype and mythologize certain populations negatively and to their


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detriment. These frameworks act as a tool to help us see differently and therefore to act differently. One example that reveals a critical way to view migration is through the work of Daniel Groody,46 a Holy Cross priest and associate professor of theology and the director of the Center for Latino Spirituality and Culture at Notre Dame University. Groody believes that migration is “also a way of thinking about God and what it means to be human in this world.”47(p3) He deepens the discussion for me, beyond the academy, sociology, anthropology, and history by reflecting on the spiritual journey of the migrant across the desert, symbol of struggle. Groody points out that the Judeo-Christian tradition is “steeped in the images of migration,”47(p4) a position enunciated by the US Catholic Bishops. His research springs from his years of work on the US-Mexico border working with immigrants, including undocumented immigrants, and listening to their stories in the mountains, deserts, and detention centers. His research covers such geographies as the US-Mexico border, the borders between Slovakia and the Ukraine, Malta and Libya, and Morocco and Spain. In all these areas, he found parallels in how immigrants experienced their journeys spiritually as well as physically, and how these 2 threads continually intersect. The profundity of these migrants’ reflections on their dual journey cannot be missed. They viewed their journey as a sacrifice, particularly leaving home and loved ones, risking the possibility they will not see their children grow up, or be able to return home for funerals, and that they might even be risking their own lives for the sake of their families and providing for them. They know they will be facing an inhospitable desert with its inherent dangers of rattlesnakes, scorpions, reptiles, and robbers, the intense heat. But Groody cites Mario, a 15-year-old Mexican immigrant “Nobody comes to the States for sightseeing or to get rich. “I’m thirsty out here in the desert, but I’m even thirstier to find work. My family is very poor, and they depend on me. We have nothing to eat, really

just beans and tortillas, and I am anxious to respond to their needs.”46(p305) These migrants speak from their depths, from their hearts. Groody also found many immigrants felt accompanied by Jesus and this belief was a source of hope, and they thought about how Jesus faced rejection and even death. But immigrants feel wounded as they are abused and humiliated, their humanity diminished. “We just want to be human, and they treat us like we are animals,” said Maria, who crossed over with a group of 40 people. “Or worse—insects!”46(p306) Yet, consistent themes of trust in God were pronounced in the midst of suffering, reminiscent of Job in the Old Testament. “All I can do is put myself in the hands of God and trust he will light my path,” said Carlos. “I do not know where I am going, or what is ahead of me, but I have to take the risks because our needs are great.”(p306-307) The courage to persist through suffering is then powerfully motivated by the love of the immigrants for their family, their impetus toward life in spite of the risk of losing that life. So the desert, mountains, or seas constitute geographical and topological landscapes migrants must traverse, as does crossing the border itself and risking detection and forced return to the country of origin. Surely migration is also embedded within a “politics of suffering.”48(p250) Nurses who work with immigrants might consider the role that spiritualities play in strengthening immigrants during their migrant journeys, in their suffering and in their hopes. For those who practice their faith, no matter their denomination, these spiritual strengths might be tapped in helping immigrants maintain health. For example, if they believe that they are made in the image of God, they can be reminded to care for their bodies well because of that spiritual belief (Rev Rudy Valenzuela, PhD, RN, FNP-BC, Personal Communication, 2011).

LANDSCAPES AND MIGRANT HEALTH How do these landscapes, undocumentedness, historical colonialism, neoliberalism,


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Borders, Centers, and Margins detention centers and deportation, and the migrant journey itself influence the health of migrants and immigrants, and how might nurses respond? These are but a few of the many landscapes migrants encounter. Nurse scholars have written about cultural landscapes, language, employment settings, health care experiences, and others. The question of health is best addressed by considering population health because individual health issues of immigrants are no different from those who are citizens by birth, and nurse scholars have also covered some of these health issues, access issues, and acceptability issues from cultural and feminist standpoints. Not to be forgotten, however, are the health strengths and agency of migrants and immigrants that keep them forging ahead such as learning new territories in the host country, learning bus and transportation systems to their advantage, finding public health clinics and schools for their children, and persistence through difficulties.19 Potential adverse health consequences of migration Trauma is a ubiquitous health problem, related to loss of one’s livelihood in ones own country due to neoliberal policies put in place there. Whether migration is internal or cross border, the loss of one’s usual means of livelihood can be a source of trauma, putting potential migrants into the position of having to decide a course of action. Trauma can also be related to the migration journey with its dangers, especially for women migrants if they are physically and sexually assaulted, and if they are abused by immigration agents. Migrants have reported that they have been threatened, verbally abused, beaten, and detained due to their ethnicity.49 They might also have been sexually assaulted in a detention center by guards. Trauma may also affect the families of immigrants who have been detained and deported, even that immigrant himself or herself. The abrupt separation from families is especially egregious and inhumane, something

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we citizens and privileged Euro-Americans cannot fathom unless it were to happen to us. Depression is also a distinct possibility related to being far from home and feeling isolated, from vulnerability, exploitation, and marginalized status, from feeling unwelcome, like a pariah, in the country of settlement, and again from family separations due to deportation of members. Children in foster care or who have lost a parent through deportation may become depressed and act out in antisocial behaviors.50 Moreover, children who are in detention centers, like the Hutto detention center in Texas, might also suffer from depression and trauma of prison-like conditions.51 Risk of suicide might be associated with severe depression, and with perceived inability to progress in one’s life due to the structural barriers against undocumented immigrants, especially young immigrants who were brought as children and remain undocumented. One such case publically known is that of Joaquin Luna, a college graduate who took his life when the US DREAM Act failed to pass last year.52 The US DREAM act would allow young undocumented immigrants who were brought as children a path to citizenship if they completed college or served in the military for 2 years. With changes in life style, increased intake of processed foods and carbohydrates, and a less physically active life, Latino immigrants especially are at risk for cardiovascular disease, prediabetes, and diabetes type 2 the longer they are here (Rev. Rudy Valenzuela, PhD, RN, Personal Communication, August 1, 2012). Migrant/immigrant families in general might be more susceptible to health inequities associated with wealth inequalities. At last, health care access is a critical issue. Having been excluded from all the provisions of the PPACA, undocumented immigrants must rely on self-pay, or community health centers or emergency departments and emergency Medicaid for their care. Even there they may be ignored, undervalued, and left inappropriately treated. Authorized low income immigrant uninsured adults who are not yet citizens must yet maintain more than 5-year


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waiting period before eligibility for Medicaid, but they are able to purchase from the state or Federal insurance exchanges starting October 1, 2013. Since 2009, with the reauthorization of the Children’s Health Insurance Program (CHIPRA), states may decide to provide Medicaid and CHIP benefits to authorized immigrant children and pregnant women. Only 29 states as of 2014, however, have chosen to do so (see the Figure).32

EMANCIPATORY NURSING: WAYS TOWARD PRAXIS Clinical nursing practice Clinically practicing nurses are on the frontlines of providing health care with immigrants. Emergency departments, school settings, and community settings are only 3 of the common arenas where nurses might encounter immigrants, both documented and

Figure. CHIPRA: new state option for coverage of legal immigrant children and pregnant women. Copyright 2009 CIHJ.


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Borders, Centers, and Margins undocumented. Undocumented immigrants will not disclose their juridical status without a deep sense of trust in a health care provider, but when and if they do, nurses have an ethical obligation to protect and maintain the confidentiality of the immigrant. This obligation is parallel to Health Insurance Portability and Accountability Act regulations that protect the health information of persons receiving health care. Practicing nurses might also know of immigrants’ communities and find ways to develop outreach programs that invite immigrants to seek care without fear of betrayal. No nurse is obliged to act as an immigration agent. Also, given the dangers of cross-border migration for women especially, nurses could be alert for any signs of past trauma or assault, and subsequent health conditions arising from these experiences in recent newcomers. It is imperative that nurses working in ICE detention centers treat these populations with dignity, compassion, and respect. Detained immigrants, especially those separated from their families, or those whose unauthorized entry was triggered by persecution in their home countries, are suffering deeply. These situations call for political advocacy by the profession and by individual nurses. Nurses as advocates Advocacy for patients and for populations and their health is one of the pillars of the profession. Only as recently as September of 2010 has the American Nurses Association (ANA) issued a resolution supporting health care access for undocumented immigrants. The basis for this resolution is founded in the belief that health care is a human right and acknowledges that both documented and undocumented immigrants face barriers to health care access.53 Historically, this resolution marks a significant expansion from its previous restricted focus on “foreign nurses”11(p136) as immigrants. The ANA Code of Ethics supports health care access for all people residing in the United Sates, regardless of their juridical status as noted in

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this newest document. Moreover, the ANA has acknowledged that undocumented immigrants suffer from health disparities, and it has pledged to educate nurses about the social, economic, and political implications when undocumented immigrants cannot access health care. As of 2012, the American Association of Colleges of Nursing, the National League for Nursing, and the Quad Council of Public Health Nursing Organizations, including the Association of Community Health Nursing Educators, do not have stated positions on immigrant health.11 The International Council of Nurses has a position statement on immigrant health as a human right and encouraged the ANA to explore this topic and issue a statement. Recently, the American Academy of Nursing has commissioned its Expert Panel on Global Health to study migration and undocumentedness (Deanne Messias, Personal communication, December 6, 2012). Speaking up for immigrant populations at the local, state, and Federal level keeps nursing consistent in its commitment to health care for all, without discrimination. Nurses could advocate for passage of the US DREAM Act and encourage state and those national nursing organizations that have not yet issued statements on immigrant health, including for undocumented immigrants, to issue position papers on such measures. Meaningful immigration reform that is family based is an urgent need that would allow undocumented immigrants, meeting certain conditions, to attain legal juridical status and eventually citizenship. Because the recent national elections immigration reform is on the horizon, the Obama Administration has identified it as a high and immediate priority (Michael Hill, Associate Director, Government Relations, United States Conference of Catholic Bishops, Personal communication, December 3, 2012). Meaningful immigration reform would facilitate improving the social determinants of health by improving the social, political, and economic conditions that improve health and health care access.


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Joining with immigrant and immigrant health advocacy groups is a credible way to educate legislators and nursing organizations with nurses’ health knowledge. For example, the Center for Immigrant Healthcare Justice (www.cihj.org) works to expand CHIPRA coverage to those states that have not yet taken advantage of this program for authorized immigrants who do not meet the 5-year qualification for Medicaid.32 The Center for Immigrant Healthcare Justice also pledges solidarity with undocumented immigrants who must rely on EDs and community health centers by calling for public and elected officials to support health care for undocumented immigrants. Knowledge development regarding the lives and health of immigrants, and of undocumented immigrants, presupposes that their social, cultural, and economic contributions to society are known and appreciated. Nurses then can use this knowledge to inform legislators, public officials, and the public based on the evidence of their claims. Nurse educators can integrate this knowledge into their teaching of health care with vulnerable populations and in nursing ethics courses. Nursing education and research The body of scholarly research from critical paradigms with immigrants and health care will always need to be augmented. One challenge would be research around the health effects of detention on detainees, and the health effects on families of members detained and deported. Research is also needed to unearth the health effects of deportation. One such recent research project in the San Diego-Tijuana border region found male deportees were more vulnerable to human immunodeficiency virus infection from female sex workers, and that they suffered greatly from “social isolation and economic dislocation.”54(p1) Research by nurses in countries of origins to which detainees have been deported is needed and offers opportunities for cross-border collaboration among nurse researchers. Nurse researchers are no strangers to cross-border collaborative re-

search efforts, so a focus on transnational migration and undocumented immigrants and their life and health-related concerns is a fertile area to develop the health knowledge and political knowledge that can influence immigration policy, and even the role of neoliberal economics in migration.

CONCLUSIONS The imposition of neoliberal economic models has displaced millions of people who have suffered terrible losses of homes, jobs, human relationships, communities, ecosystems upon which they have depended for centuries, and even lives. It has produced an exponential increase in migration, including unauthorized migration and the attendant health issues related to immigrant/migrant health. Neoliberalism cannot be decoupled from health status, health risks, health care access, and affordability for migrants, particularly irregular transnational migrants. The development of sociopolitical knowing, a concept first articulated by White,55 is crucial for understanding the complex migration patterns of the 21st century. Uncovering more of the dynamics and history of neoliberalism, and the growth of the for-profit detention industry along neoliberal lines, consistent with the use of critical paradigm that upset the status quo, can emancipate our understandings and our work in clinical practice, research, education, and political advocacy to improve the lives and health of immigrants, including undocumented immigrants. The parallels between the United States and the EU are striking and invite nursing to more collaborative ventures in exploring migration and health issues in sending and receiving countries, launching these efforts as a global endeavor for nursing. Nursing needs new horizons that transcend current boundaries of practice, education, research, and advocacy. Critically examining all the landscapes influencing migration and health will provide us with better tools with which to address this urgent issue in the 21st century.


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Europe's responsibility to refugees: health beyond borders.

Eating and Feeding at the Margins of the State: Barriers to Health Care for Undocumented Migrant Women and the "Clinical" Aspects of Food Assistance.

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Quality measurement indicators for Iranian Health Centers.

Dilemmas for psychologists in mental health centers.

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Cultural Health Practices of Migrant Seasonal Farmworkers.

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Walking beyond our borders with frontline health workers in Guatemala.

Health situation of migrant and minority nurses: A systematic review.

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A model program for providing health services for migrant farmworker mothers and children.

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