AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. June 2001, Volume 3, Number 6.

Images of Healing and Learning

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Migrating Pathogens: Creating Fear of Health Risks

A medical student illustrates the damaging effects that stereotyping of immigrants has on the availability and receipt of health care and on the medical system itself.

Maria Ruiz

By assessing the symbols and images that diseases attract we can come to understand the complex phenomenon of illness [1].

During the turn of the 20th century when immigration to the United States was at its peak, immigrants were the target of anxieties over what "face" (racial, class, and cultural characteristics) the nation would have [2]. Immigrants were associated with disease, and public health measures were employed in regulating and disciplining immigrants. One of the important lessons that historians provide is that the association of immigrants with disease has health consequences which result in a cycle of discrimination and disease that reinforces the association of immigrants with contamination [3]. Stigma not only promoted the spread of disease by reinforcing prejudice, but also created fear and mistrust which distanced new immigrants from the medical establishment. In light of currently high rates of "new" (and non-European) immigrants, those concerned with racial and ethnic disparities should take note of these historical lessons. Although health disparities are well documented, the reasons for their existence remain elusive. A recent Kaiser Family Foundation study concludes that racial and ethnic health disparities are "complex" and "difficult to quantify" [4]. As suggested by Brandt, images provide a rich medium by which certain "data" such as attitudes, fears and anxieties, and political context can be qualitatively evaluated [5].

A January 1997 cover of American Family Physician (AFP) entitled "Emerging Infectious Diseases: A Challenge to All," illustrates the increasingly interconnected anxieties surrounding disease, borders, and immigration. The AFP cover features an unfolded map of a portion of North America. Bacteria, parasites, and other pathogens frame the United States, while bright bursts dot and accentuate its borders. Although the bursts are not explicitly labeled as such, in relation to the topic of emerging infectious disease (EID) they most likely represent disease outbreaks. A mouse straddles the US-Mexico border and points north while a tick hovers above the Canadian border. Looking at this image, how do we read the relationship between borders, disease, and migration? What are the major concerns and priorities communicated in this image? What are the connections between this image and current heated debates about immigration, the US-Mexico border, and immigrants' rights to quality health care?

Contrary to the title and the text of the article (described below) which suggest that EIDs are everyone's problem, this image represents EID as a foreign threat which has selectively compromised the integrity of US borders, as well as the health of US residents. One predominant theme is that of migration, as suggested most strongly by the unfolded map, and the animal and insect that have walked upon it and point towards the United States as their final destination. These travels are not innocent, as evidenced by the explosions that occur at strategic points along the borders, but rather are clandestine border crossings that threaten US national security.

This essay concerns images of the US-Mexico border and associations of Latino/a immigrants with disease rather than coverage of EID, per se. However, it is worth noting the discordance between how EID is represented in the cover image and how it is discussed in the text of the article [6]. Although the author, LJ Strausbaugh briefly mentions some of the more "exotic" diseases publicized in the mainstream press (e.g., Ebola virus), for the most part, Strausbaugh focuses on diseases that are either endemic to the US (e.g., ehrlichiosis), are nosocomial infections (e.g., vancomycin-resistant enterococci), or are spread by poor food preparation methods (e.g., E. coli 0157:H7). "International travel and commerce" are listed as only one factor among many that are responsible for EID. Others include "changes in human demographics and behavior," "changes in technology and industry," "economic developments and land use," "microbial adaptation and change," and "breakdown of public health measures" [7]. Although the AFP image successfully draws attention to the importance of EID, it does so by drawing on familiar narratives of apocalyptic disease threats that originate from outside the boundaries of the nation; brought on by "Third World" people and pathogens encroaching on the US. The linkage between disease and border crossings does more than compare the problem of the borders to the problem of infectious diseases; the linkage assigns blame for one onto the other.

One of the possible repercussions of the APF cover image then is that, intentionally or not, it supports an increasing border patrol mentality in regard to immigrants and medicine, with implications for health interventions. In 1994, Proposition 187 was passed in California. If implemented, it would have mandated that health care workers verify the documents of those "suspected of being illegal," and report the undocumented to the Immigration and Naturalization Service (INS). Proponents of Proposition 187 drew on the stereotype of the dirty and diseased Mexican to support their claim that the US health care system was a magnet that attracted undocumented immigrants to the United States. Though Proposition 187 was held up in courts for many years before it was ruled unconstitutional, its legacy of fear and confusion have had lasting effects for access to health care for those who fit the stereotype of the illegal alien, namely non-European racial and ethnic groups, and the foreign-born. Federal legislation in 1996 made many legal immigrants ineligible for publicly funded non-emergency health care [8].

Furthermore, the AFP image has particular implications in the clinical setting, as it is circulated among physicians, nurses, medical students, and hospital administrators. Most worrisome is that immigrants are seen as disease vectors—like the mouse and the tick—rather than people that themselves suffer from disease. Also, images such as these may affirm nativist sentiments and contribute to the hostility, scorn, and "subtle and not-so subtle discrimination" that immigrants already face in the hospital or clinic [9].

I believe that border anxiety is shaping health care in the US. But can we imagine the alternatives? If, as Williams and Rucker argue, racial and ethnic heath disparities were a national priority, and if "renewed regulatory vigilance" of discrimination in regards to health care were implemented, then we might be able to read the AFP from the point of view of the medically marginalized [10]. Each of the blastpoints could represent different factors that have increased the incidence of disease along the US-Mexico border and among immigrants: the widening gap between rich and poor, lack of insurance for the working poor, toxic waste dumping on the border, and an extreme lack of Spanish-speaking health professionals. These factors cause disease along the borders and should also be seen as emerging threats to the health of people living in the United States [11].


  1. Brandt A. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880. New York: Oxford University Press; 1985:5.
  2. Markel H, Stern AM. Which face? Whose nation? Immigration, public health and the construction of disease at America's posts and borders, 1891-1928. Amer Behavioral Scientist. 1999;42:1314-1331.
  3. Alan Kraut has written the most thorough historical account of the association of immigrants with disease. Kraut AM. Silent Travelers: Germs, Genes, and the "Immigrant Menace." New York: Basic Books; 1994. See also: Markel H, Stern AM (1999). Brandt A. (1985), Tomes N. The Gospel of Germs: Men, Women, and the Microbe in American Life. Cambridge, Massachusetts: Harvard University Press. 1998, and Ehrenreich B, English D. Complaints and Disorders: The Sexual Politics of Sickness. New York: The Feminist Press; 1973.
  4. Henry J. Kaiser Family Foundation. A Synthesis of the Literature: Racial & Ethnic Differences in Access to Medical Care. Menlo Park, California: Henry J. Kaiser Family Foundation. 1999:25.
  5. For a further analysis of representations and disease see Treichler P. How To Have Theory in an Epidemic: Cultural Chronicles of AIDS. Durham: Duke University Press; 1999, Martin E. Flexible Bodies: The Role of Immunity in American Culture from the Days of Polio to the Age of AIDS. Boston: Beacon Press; 1994, and Sontag S. Illness as Metaphor. New York: Farrar, Straus, Giroux; 1978.
  6. Strausbaugh LJ. Emerging infectious diseases: A challenge to all. Amer Fam Phys. 1997;55:11-117.
  7. Ibid., 113, Table 3. For an excellent discussion of mainstream media coverage of emerging infectious diseases and implications for prioritizing global health threats, see McGee DE. Emerging meanings: Science, the media and infectious diseases. JAMA. 1996; 276:1095-1097.
  8. Federal immigration reform legislation passed in 1996 includes the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) and the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA). For an overview of recent legislation as it impacts on immigrant health see Ivey SL. Welfare and immigration reforms in 1996 and 1997. In: Kramer E, Ivey SL, Ying YW, eds. Immigrant Women's Health: Problems and Solutions. San Francisco: Jossey-Bass Publishers; 1999:66-71, Mizoguchi N. Proposition 187: California's anti-immigrant statue. In: Kramer E, Ivey SL, Ying YW, eds. Immigrant Women's Health: Problems and Solutions. San Francisco: Jossey-Bass Publishers; 1999:72-77.
  9. Tahan H. Subtle and not-so-subtle insensitivity to ethnic diversity. JONA. 1998;28:11-14 and Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Minority Health Today. 2000; 2:30-39.
  10. Ibid.
  11. See the following literature for information regarding the points mentioned in this paragraph: Kim JY, Millen JV, et al, eds. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Maine: Common Courage Press. 2000, McMichael A, Beaglehole R. The changing global context of public health. Lancet. 2000; 356:495-498, Skolnick AA. Along US southern border, pollution, poverty, ignorance, and greed threaten nation's health. JAMA. 1995;273:1478-1482, Warner DC. Health issues at the US-Mexican border. JAMA. 1991;265:242-247.

Maria V. Ruiz, MD, is a third year medical student and a PhD candidate in the Medical Scholars Program of the University of Illinois at Urbana-Champaign. She is currently writing her dissertation, "Border Narratives, HIV/AIDS, and Latino Health in the United States: A Cultural Analysis."

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