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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 400, San Diego, California 92122
It is often said, and appropriately so, that the U.S. is a country of immigrants. In my own case, all four of my grandparents were born and raised in Europe before coming to the U.S. Our immigrant origins are often credited for the diversity and openness of our culture. Nevertheless, immigration is now the topic of a spirited debate, particularly when illegal. For the past several April days, our San Diego newspaper carried three immigration stories: one about President Bush’s plan to facilitate immigration, a second describing volunteers who patrol the border between Arizona and Mexico for illegal crossings, and a third detailing competition for leadership of the Sierra Club between factions in favor of and opposing immigration. However, despite the prominence of immigration in our national discourse, physicians and the medical profession have been largely silent on the issue.
The pros and cons regarding an “open borders” immigration policy have been well spelled out and do not need to be repeated in detail. Immigrants generally fill low-paying jobs that U.S. citizens appear unwilling to take. From a practical standpoint, those advocating open immigration have pointed out that undocumented workers are already here and form a significant portion of the workplace. The U.S. Immigration and Naturalization Service estimates that there are more than seven million illegal immigrants currently living in the country, and the national economy would be compromised were they to be displaced. In fact, a shortfall in the number of workers required by the U.S. economy is projected in the future. Those in favor of limiting immigration point to the adverse environmental consequences of an expanding population, and the fact that the wages for the jobs they fill become depressed. Although a point of major contention, foes claim that immigrants use abundant government services, generating a cost to the economy which outweighs their contributions. With regard to illegal workers, it is argued that their behavior weakens respect for our laws and that it is wrong to reward those who have broken the law rather than apply for legal entry and wait for approval.
There are, of course, a number of important medical issues related to immigration. To begin with, the potential exists for immigrants to bring communicable diseases with them. Tuberculosis (including multiple drug-resistant strains), hepatitis, and HIV have attracted the most attention. For those immigrants who are illegal, there is no screening for existing disease at all. Second, most immigrants are poor, so that health care is often neglected or sought from emergency departments, frequently for conditions for which the emergency department was not intended. Therapy is often not available after the initial emergency department visit, resulting in recurrences. This may be especially difficult in cardiology, such as when a patient with heart failure due to valvular disease is compensated, but then is not eligible for surgical intervention. Finally, payment for the medical services rendered is usually lacking. Thereby, an enormous financial burden can be placed on individual institutions such as those in border states like California and Texas.
In view of the aforementioned, the medical community would seem to have a major stake in the immigration issue. It is therefore surprising to me that we have been somewhat slow to speak out on this matter. I think we view our role as physicians is merely to prevent or manage illness wherever and in whomever it is found. We see ourselves as the patient’s advocate, and find it illogical to think that the ability to receive medical treatment should depend on where one was born. Even here in San Diego where immigrants, legal and illegal, are encountered daily, not much discourse is heard on the topic in medical circles. Although the problems surrounding immigration are incredibly complex, and no simple solution is likely to be found, it would be important for us to have well thought out position on alternatives.
It has been suggested that we should deny non-emergency health care to illegal immigrants, and in fact report such individuals to government authorities. I see little benefit or rationale for this plan. Physicians are not policemen, and with rare exception should not be charged with enforcing laws. It makes little sense to allow immigrants to develop or suffer from a potentially transmittable disease which could be communicated widely. Even from a financial standpoint, prevention and early treatment of disease is cheaper than treating a critically ill patient.
In my opinion, the health care aspects of the immigration issue attest to how dysfunctional, and in need of reform our current system is. We pass laws forbidding undocumented workers from entering the country, exert little effort to prevent them from doing so, and then reward them with jobs and social services when they do. In the process we create a near permanent underclass with substandard health care and the potential for introduction of transmissible disease and a profound negative financial impact on medical facilities. Moreover, the financial burden is not shared equally throughout the country, but is imposed on selected facilities and practitioners. To say that our immigration system is in desperate need of reform would be the grossest of understatements.
Whether it is for environmental, security, medical, or financial reasons, I believe that the U.S. must take control of immigration. In my view, this would begin by controlling the border. It should then be determined how many workers are required or can be accommodated and for which jobs. Entry into the country could then be reasonably arranged and documented. I would favor including some screening for transmissible medical conditions. These immigrants could then receive an appropriate wage, health care, and educational benefits and be vigorous participants in society. Individuals circumventing this process, either by seeking employment or employees, should be prosecuted. Finally, because the entire country benefits from the financial contributions of immigrants, the federal government should establish a system that will provide equitable reimbursement to those institutions and individuals providing medical care to them.
Immigration is not generally thought of as a medical issue, nor should it be. However, the medical consequences of immigration, either in terms of potential disease or financial burden, are among the most important aspects of this issue. The immigration system is in dire need of restructuring, and no greater evidence of this exists than the potential and actual consequences it has on health care. As such, we as physicians should be among the most vocal advocates for reform.
- American College of Cardiology Foundation