Sovereignty, Citizenship and Public Health in the United States

Abstract

Sovereign boundaries, state borders, and distinctions between citizens and non-citizens undermine public health in the United States in a number of ways. For historical reasons, we are prone to view immigration and public health as separate interests, but they are in fact convergent. Historically, federal authority over immigration alleviated costs otherwise borne by state and local governments. Today, however, states are primarily responsible for the prevention and control of communicable disease acquired outside U.S. borders. The federal and state governments confront a stark division of authority with respect to non-citizens: The federal government decides which non-citizens to admit into the country and the terms under which they may stay, while states must cover the costs of foreign nationals who present a public health threat within the United States. Our system of federalism and a fragmented public health infrastructure mean that the cost of health control measures falls on state and local governments, with uneven effectiveness and greatly disproportionate impact in some communities. The problem is thus systemic: the fragmented structure of public health agencies in the United States can prevent an effective response to even wholly local epidemics. Nonetheless, because immigration laws affect public health in many complicated ways, we can make progress by addressing the externalities of public health problems through creative approaches to federal law, along with providing the resources needed to support these changes. This Article concludes with a discussion of a specific public health threat — drug-resistant tuberculosis — to provide a compelling context for the problems I identify.

Keywords: immigration, public health, tuberculosis, drug-resistant tuberculosis, Mexico, Border Health Commission, CDC, quarantine, isolation, state police power, migrants, illegal immigrants, undocumented, health inspection, exclusion, visa, ICE, detention, immigration enforcement; asylum, 'do not fly' list