University of California, Department of Social and Behavioral Sciences, 3333 California Street, Suite 455, San Francisco, CA, 94143-0612, USA.
Soc Sci Med. 2019 Aug;235:112411. doi: 10.1016/j.socscimed.2019.112411. Epub 2019 Jul 9.
Contemporary U.S. health and immigration policies exclude millions of noncitizens from healthcare coverage. Growing scholarship emphasizes legal status as a technology of social exclusion and determinant of health, but few studies capture the effects of recent policy uncertainty on noncitizen health. By examining the case of Coral County (a pseudonym), I highlight the challenges facing safety-net clinics and their noncitizen patients making life and death decisions amidst uncertainty before and after the 2016 presidential election. Observational and interview data with patients, clinic workers, and community partners (n = 27) revealed that growing anxiety over federal immigration policies altered clinical risk calculations through a process I refer to as "medical legal violence" (MLV). Whereas previous risk negotiation strategies leveraged bureaucratic routines to elevate imminent threats of illness and/or injury in health decisions, heightened immigration enforcement under the Trump administration shifted the balance in clinical risk calculations toward social risks of detention, deportation, and family separation. This transformed clinical care in Coral County by turning trusted medical-legal bureaucracies into potential tools for federal biopolitical surveillance of immigrant patients, blocking healthcare pathways and increasing patients' fear and anxiety.
当代美国的卫生和移民政策将数百万非公民排除在医疗保健范围之外。越来越多的学术研究强调法律地位是社会排斥的一种技术和健康的决定因素，但很少有研究能捕捉到最近政策不确定性对非公民健康的影响。通过考察珊瑚县（一个化名）的案例，我强调了在 2016 年总统选举前后，面对政策不确定性，医保诊所及其非公民患者在生死攸关的决策中所面临的挑战。对患者、诊所工作人员和社区合作伙伴（n=27）的观察性和访谈数据显示，对联邦移民政策的日益担忧通过我称之为“医疗法律暴力”（MLV）的过程改变了临床风险计算。虽然之前的风险协商策略利用官僚程序在健康决策中提高疾病和/或伤害的迫在眉睫的威胁，但在特朗普政府领导下，移民执法力度的加强将临床风险计算的平衡转向了拘留、驱逐和家庭分离的社会风险。这通过将可信赖的医疗法律官僚机构转变为联邦对移民患者进行生物政治监控的潜在工具，阻断了医疗保健途径，并增加了患者的恐惧和焦虑，从而改变了珊瑚县的临床护理。
