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From explicit tabloid media’s racial ‘othering’ of migrants to the more implicit racial tonality of political rhetoric and immigration policy, race undeniably plays a major role in political and media discourse surrounding migration. This ‘racialisation’ of migrants is a form of culturalism that can be defined as a “racism without race,” in which migrants are discriminated against because of their cultural difference and perceived threat to national autonomy and safety. We see the racialisation of migration surface in debates about immigration, assimilation, and multiculturalism, and in the myriad ways it contours migrant experience, but what role does it play in migrant health?
It is with this question that the second webinar in the Borderings series emerged, adding a further layer to the already complex nexus of migration, gender and health. Spiralling through dialectics of disease and racial states, neo-racism and cultural competency, the panel crafted a rich and complex image of how conceptions of race, racialisation and neo-racism have become a determinant of migrant health.
Race, displacement and COVID-19: Dialectics of Disease in the Racial State
Dr Emma Hill, interdisciplinary researcher at the University of Edinburgh and Research Fellow on the GLIMER Project, opened the discussion with a reflection on how the pandemic has exposed long-held racialised attitudes to migrants, drawing on her recent paper ‘Rethinking Refuge in the time of COVID-19’ co-authored by Nasar Meer, Timothy Peace and Leslie Villegas.
COVID-19 has profoundly reduced the global movement of people. As early as April 2020, roughly 46,000 new travel restrictions had been imposed by individual states and whole regional blocks, including the closure of borders to asylum seekers and refugees. COVID curtailment of displaced migrant’s mobility has, in turn, led to increasingly restrictive, under-resourced and negligent internal bordering practices. In the UK alone, Emma noted, examples include the rise of hotel detention for asylum seekers who have been refused, the development of increasingly controversial reception centres as well as social isolation and impoverishment caused by policies such as ‘no recourse to public funds’.
In COVID-19, Emma continued, we are witnessing a drive towards the increased immobilisation of migrants, asylum seekers and refugees tenored in the language of disease and infection control.
In this context of immobilisation, Emma questioned; how might existing theorisations of displaced migration, including those of race and racialisation, help contextualise and understand what is happening in this time of pandemic?
As Emma argued, whilst these strategies of infection control and the language of disease are facilitated by the environment of the current pandemic, there are ample pre-COVID examples of medicalised racism within the representational economy of disease. From the the naming of late-nineteenth century outbreaks of TB as the ‘Jewish disease’ to the UK Aliens Order in the 1920s that identified refugees as ‘unsanitary aliens’ whose movement was restricted on the grounds of public health, the discursive strand of immigration as a ‘disease’ has a long and distinctive genealogy. Today, it is easy to find evidence of medicalised prejudice in the anti-immigrant rhetoric that describes displaced migrants as ‘swarms’ that ‘swamp’ the system.
For Emma and colleagues, the association of refuge with disease can be best analysed in reference to the body politic, in which nation-states become analogous to a body in need of protection from infection, invasion and penetration of disease. In this analogy, citizens form the body, while migrants, asylum seekers and refugees are considered not only “foreign” or Other, but also potential “threats” to the wellness, “purity” and resilience of the body of the nation. Reading the dialogic of disease in this way, Emma continued, the preoccupation with infection control is not simply an expression of anxiety resulting from fear of further infection within pandemic, but rather a political sleight of hand, in which asylum seekers and refugees are framed not simply as carriers of disease, but as the disease themselves. It reveals it to be technology of control in which viral prevention policies become synonymous with asylum seekers and refugees.
Emma concluded that it is clear to see the racialised dynamics emerge when reading the language of disease through David Theo Goldberg’s theory of the racial state, which argues that modern nation-states are in fact “racial states” whose purpose is to maintain white hegemony. In this, race is understood as a key organising force of the nation and a major faultline through which factors such as citizenship, access to the nation and belonging are hierarchized. In the racial state, migrants, asylum seekers and refugees, more specifically those from the Global South, are racialised as Other and subhuman in contrast to the white and developed nation-state. Read in this way, new depths of meaning emerge from within the pandemic imaginary. The motifs of social distancing, quarantines and border closures to asylum seekers and refugees emerge as a means of maintaining the racist economy of citizenship and representation. And the threat of viral infection is revealed to be a means of maintaining the ‘racial purity’ of the nation-state from the threat of ‘racial infection’.
Discrimination and Health: The Cost of Neo-Racism
Moving through the racial state to neo-racism, Dr Susanna Corona Maioli, a doctor and PhD candidate at University College London, kicked off her presentation with a discussion on how and why neo-racism contours migrant health. Susanna explained, where ‘traditional’ racism focuses on a biological hierarchy, neo-racism focuses on cultural hierarchy in which nations are not only believed to be fundamentally different but also to exist within a hierarchy premised on those differences. In this, neo-racism intersects and is deeply embedded in traditional racism, since the dominant, oppressing, culture is mostly Western and white.
But why does neo-racism proliferate, and arguably increase, in times of crisis? Susanna answered blunty; neo-racism justifies unfairness and unfairness is deemed profitable. The belief that there are fundamental differences between peoples, and that these differences justify differential degrees of access to resources, power and quality of life, excuses exploitative neoliberalist practices and ensures the maintenance of power structures for the privileged groups (read white and male) that keep systemic inequality in place. But don’t be fooled, Susanna warned, while the minoritised and discriminated bear the brunt of inequality, the cost of neo-racism is ultimately paid by everyone.
Susanna continued, racial gaps in health in the United States cost the economy hundreds of billions of dollars a year in healthcare costs and lost productivity, while cuts in welfare through migrant scapegoating only increases the burden placed on healthcare systems. For example, in the UK, restrictions on migrant’s access to NHS services were justified as an austerity measure, but in practice the bureaucratic costs of implementing such barriers to care completely offset the possible gains. As Susanna emphatically illustrated, a unified, inclusive healthcare system is far more efficient- a truism that has been sharply exposed in COVID-19.
Moreover, Susanna argued, it is in part the distrust, fear and misinformation created by healthcare systems, their exclusionary practices and neo-racist discourses, that has led to the deadly lack-of-control over the spread of COVID-19. Indeed, when migrants are afraid to access healthcare services for fear of deportation, it is impossible to test, track and treat the highly contagious virus. And as the virus spreads across the self-imposed borders of nations, exposing the porosity of the body politic, dubious prevention strategies in detention centres and deportations leave everyone at greater risk.
In the US, for example, reports of people ill with Coronavirus deported from pandemic epicenters to countries with fragile health systems such as Mexico and Central America led to both a spike in cases as well as fear and anxiety within the home countries. While elsewhere, in Australia, a country largely praised for their COVID response, concerns regarding the conditions in immigration detention facilities (hand sanitizer without alcohol, overcrowding, staff without PPE, reopening of Christmas island for people who cannot be deported), have sparked global conversations about how vulnerable groups are being neglected in national pandemic responses.
As Susanna concluded, within a system that scapegoats migrants and blurs the lines between healthcare and border enforcement, not only is migrant health racialised but so too is global and planetary health compromised.
‘The State Outside / The State Within’: Clinical Encounters
Both Emma and Susanna’s presentations answered the posed question- ‘is migrant health racialised?’ with a resounding yes. Through their discussions they illustrated the legacies of racialisation that have produced the situation migrants and displaced peoples now find themselves in, and explored the neo-racist policies and discourses that render migrant health vulnerable. But how do the processes of racialisation emerge in the clinical encounter?
Taking us to the level of practical engagement, the final speaker, Natasha Chilambo, a final year medical student at King’s College London, situated her presentation in the doctor’s surgery.
In a recent placement at a local GP, Natasha described how she found herself in an encounter that exposed the fault lines in the UK care system and brought her face-to-face with the limits of her medical education.
The patient was an elderly woman, a Syrian who had recently been granted refuge in the UK, who had come to the doctors with an ear ache and dizziness. The patient was accompanied by her daughter who tried her best to translate for her mother. In the consultation room, Natasha recounts a hostile atmosphere in which a frustrated clinician raised her voice and dismissed their concerns while refusing to transfer the patient to secondary services deeming ‘it was not her job nor her responsibility’. As tensions grew, both mother and daughter broke down into tears as the mother produced her ID, placing it in front of both Natasha and the clinician.
For Natasha, this moment illustrated the reciprocal relationship of what she refers to as the state outside and the state within. In that tearful exchange, she saw the trace of systems, policies, technologies and histories designed to racialise bodies and marginalise migrant health.
Spiralling through the origins of the NHS and the deeply interrelated history of immigration and exclusion in the UK, Natasha weaved together the systemic ways in which vast numbers of migrants have been excluded from the UK healthcare system.
Through the 1950s riots in Nottingham and Nottinghill that exploded in opposition to the influx of black and brown migrants to the UK, through the rhetorical tropes of migrants as social parasites leeching off the NHS, and into the immigration act of 2014 in which Theresa May explicitly declared the UK’s hostile environment stance, and into the switch from resident to indefinite leave to remain via the pervasive myth of ‘health tourism’; Natasha explored a complex and interwoven history of the NHS and the home office.
It was this history, Natasha continued, combined with centuries of racialisation that produced the moment that she found herself in; a clinical encounter in which a clinician embodied the state in such a way that a patient felt it necessary to produce formal identification.
As a medical student, Natasha was left wondering how much of a role medical education and curricula played in the escalation of situations such as these. Indeed, recognising and disrupting such racialising processes requires a thick appreciation of the historical and socio-political context; a high degree of cultural competency is necessary to understand how social context matters for health, treatment compliance and medical literacy. And yet, in Natasha’s experience of medical education, there was a clear preference to teach a kind of biomedical reductionism.
In fact, in the 5 years it takes to train a medical doctor, Natasha illustrated that only 1.8% of the curriculum was dedicated to thinking about the social determinants of health and broader social constructs. Even within that 1.8%, Natasha argued, the discourse is so diluted that it would be very difficult to operationalise in the clinical encounter. In a series of focus groups with other medical students at King’s College London, Natasha and colleagues sought to identify the average experience of teaching, the feedback was damning:
- Teaching on social aspects of health often homogenised and essentialised ethnic minorities, positioning them as ‘Other’ to the white idealised subject.
- The social was often reduced to social history e.g. does the patient have a history with alcohol, drugs, smoking?
- Students are not engaged with the teaching and classes on social determinants remain poorly attended
To Natasha, it is clear that we are missing key educational opportunities to interrogate and grapple with complex topics and are instead reflecting in tokenistic and shallow ways. She questioned, within such a culture of reductionism, how do we train doctors to engage with complexity?
To answer, Natasha concluded her presentation with a painting, ‘Free the Storm’ by Dora Lam and proposed a different system, that like Jazz, embraces the tension; disrupting, deconstructing and reconstructing through difference. She called for the medical community to forge new epistemic cultures, to be flexible and embracing of other ways of knowing and to take a trans-disciplinary approach that considers the social, the ethical and the historical alongside the biomedical. In essence, she asked, that we embrace the chaos.
Conclusion: Embracing the Chaos
Embracing the chaos feels an appropriate message to conclude this reflection. Although the second of the borderings webinars was well attended with a mix of students, policy experts, academics and others with an interest in the subject dialing in from around the world to hear from the speakers, the chat and Q&A at the beginning of the event was overwhelmed by trolls leaving hateful and racist messages.
The trolls that disrupted the event are testament to the turbulent and divided times in which we live, where concepts of race, racism and migration continue to provoke violent and virulent reactions. But they are also a reminder of the importance of talking about these issues, and of being vigilant of the processes - cultural, linguistic, political, social and historical- that continue to shape migrant health.
You can watch the full webinar here.
For questions or queries relating to the series please contact Imogen Bakelmun at [email protected].