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Risky Subjects, Subjects at Risk: HPV Vaccination and the Neoliberal Turn in Public Health
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Parents employ various strategies to make decisions they believe are in their children's best interests. Their decisions are informed by and reflect a complex web of meaning made up of interpretations of culture, experience, tradition, media, peers, expert advice, and their own sense of morality (Bobel 2001; Hulbert 2003; Lareau 2003). The interplay between parents' interpretations of cultural meaning and parenting strategies can be seen most clearly in parents' decisions whether to consent to childhood immunizations. Although all states require certain vaccinations to attend schools, the safety and necessity of vaccines remain controversial (Colgrove 2006). The availability of a vaccine against human papillomavirus raises additional issues as well (Casper and Carpenter 2008). As an elective vaccine not marketed for the collective good (an ethos that underscores compulsory childhood vaccine laws) but for individual benefit against a virus that is transmitted through sexual contact, it prompts new questions. Using multiple sources of qualitative data from interviews with parents and from Web sites aiming to support parents who choose to refuse vaccinations, I explicate this complex interplay in the lives of families as they contemplate vaccine choices more generally and the HPV vaccine specifically. In this. © 2010 The Johns Hopkins University Press. All rights reserved.
The first social transformation of American medicine institutionally established medicine by the end World War II. In the next decades, medicalization-the expansion of medical jurisdiction, authority, and practices into new realms-became widespread. Since about 1985, dramatic changes in both the organization and practices of contemporary biomedicine, implemented largely through the integration of technoscientific innovations, have been coalescing into what the authors call biomedicalization, a second "transformation" of American medicine. Biomedicalization describes the increasingly complex, multisited, multidirectional processes of medicalization, both extended and reconstituted through the new social forms of highly technoscientific biomedicine. The historical shift from medicalization to biomedicalization is one from control over biomedical phenomena to transformations of them. Five key interactive processes both engender biomedicalization and are produced through it: (1) the political economic reconstitution of the vast sector of biomedicine; (2) the focus on health itself and the elaboration of risk and surveillance biomedicines; (3) the increasingly technological and scientific nature of biomedicine; (4) transformations in how biomedical knowledges are produced, distributed, and consumed, and in medical information management; and (5) transformations of bodies to include new properties and the production of new individual and collective technoscientific identities.
Throughout the 20th century, US public health and immigration policies intersected with and informed one another in the country's response to Mexican immigration. Three historical episodes illustrate how perceived racial differences influenced disease diagnosis: a 1916 typhus outbreak, the midcentury Bracero Program, and medical deportations that are taking place today. Disease, or just the threat of it, marked Mexicans as foreign, just as much as phenotype, native language, accent, or clothing. A focus on race rendered other factors and structures, such as poor working conditions or structural inequalities in health care, invisible. This attitude had long-term effects on immigration policy, as well as on how Mexicans were received in the United States.
Infection with genital human papillomavirus (HPV) may cause anogenital cancers, oropharyngeal cancers, anogenital warts, and respiratory papillomas. Two prophylactic vaccines (a bivalent and a quadrivalent vaccine) are now licensed and currently in use in a number of countries. Both vaccines prevent infection with HPV-16 and HPV-18, which together cause approximately 70% of cervical cancers, and clinical trials have demonstrated 90%-100% efficacy in preventing precancerous cervical lesions attributable to HPV-16 and HPV-18. One vaccine also prevents HPV-6 and HPV-11, which cause 90% of genital warts. A growing literature describes psychosocial, interpersonal, organizational, and societal factors that influence HPV vaccination acceptability. This review summarizes the current literature and presents an integrated perspective, taking into account these diverse influences. The resulting integrated framework can be used as a heuristic tool for organizing factors at multiple levels to guide intervention development and future research.
US Hispanic women have higher cervical cancer incidence rates than non-Hispanic White and African-American women and lower rates of cervical cancer screening. Knowledge, attitudes, and cultural beliefs may play a role in higher rates of infection of human papillomavirus (HPV) and decisions about subsequent diagnosis and treatment of cervical cancer.
To explore the level of HPV knowledge, attitudes, and cultural beliefs among Hispanic men and women on the Texas-Mexico border. METHODOLOGICAL APPROACH: Informed by feminist ethnography, the authors used an interpretive approach to understand local respondents' concerns and interests. Focus group sessions were analyzed using thematic content analysis. RECRUITMENT AND SAMPLE: Promotoras (lay health workers) recruited participants using convenience sampling methods. Group sessions were held in public service centers in Brownsville. Participants' ages ranged from 19 to 76 years. METHODS ANALYSIS: Focus group discussions were audio-recorded and transcribed in Spanish. Researchers read and discussed all the transcripts and generated a coding list. Transcripts were coded using ATLAS.ti 5.0.
Participants had little understanding about HPV and its role in the etiology of cervical cancer. Attitudes and concerns differed by gender. Women interpreted a diagnosis of HPV as a diagnosis of cancer and expressed fatalistic beliefs about its treatment. Men initially interpreted a diagnosis of HPV as an indication of their partners' infidelity, but after reflecting upon the ambiguity of HPV transmission, attributed their initial reaction to cultural ideals of machismo. Men ultimately were interested in helping their partners seek care in the event of a positive diagnosis.
Results suggest that understanding Hispanics' cultural norms and values concerning disease, sexuality, and gender is essential to the design and implementation of interventions to prevent and treat HPV and cervical cancer.
The US Public Health Service began the medical examination of immigrants at US ports in 1891. By 1924, national origin had become a means to justify broad-based exclusion of immigrants after Congress passed legislation restricting immigration from southern and eastern European countries. This legislation was passed based on the alleged genetic inferiority of southern and eastern Europeans. Since 1987, the United States has prohibited the entrance of immigrants infected with the human immunodeficiency virus (HIV). On the surface, a policy of excluding individuals with an inevitably fatal "communicable disease of public health significance" rests solidly in the tradition of protecting public health. But excluding immigrants with HIV is also a policy that, in practice, resembles the 1924 tradition of selective racial restriction of immigrants from "dangerous nations." Since the early 1980s, the United States has erected barriers against immigrants from particular Caribbean and African nations, whose citizens were thought to pose a threat of infecting the US blood supply with HIV.
Neoliberalism--the doctrine that market exchange is an ethic in itself, capable of acting as a guide for all human action--has become dominant in both thought and practice throughout much of the world since 1970 or so. Writing for a wide audience, David Harvey, author of The New Imperialism and The Condition of Postmodernity, here tells the political-economic story of where neoliberalization came from and how it proliferated on the world stage. Through critical engagement with this history, he constructs a framework, not only for analyzing the political and economic dangers that now surround us, but also for assessing the prospects for the more socially just alternatives being advocated by many oppositional movements.
The influenza pandemic of 1918–1919 coincided with a major wave of immigration to the United States. More than 23.5 million newcomers arrived between 1880 and the 1920s, mostly from Southern and Eastern Europe, Asia, Canada, and Mexico. During earlier epidemics, the foreign-born were often stigmatized as disease carriers whose very presence endangered their hosts. Because this influenza struck individuals of all groups and classes throughout the country, no single immigrant group was blamed, although there were many local cases of medicalized prejudice. The foreign-born needed information and assistance in coping with influenza. Among the two largest immigrant groups, Southern Italians and Eastern European Jews, immigrant physicians, community spokes-people, newspapers, and religious and fraternal groups shouldered the burden. They disseminated public health information to their respective communities in culturally sensitive manners and in the languages the newcomers understood, offering crucial services to immigrants and American public health officials.
In 2007, Texas governor Rick Perry issued an executive order requiring that all females entering sixth grade be vaccinated against the human papillomavirus (HPV), igniting national debate that echoed arguments heard across the globe over public policy, sexual health, and the politics of vaccination. Three Shots at Prevention explores the contentious disputes surrounding the controversial vaccine intended to protect against HPV, the most common sexually transmitted infection. When the HPV vaccine first came to the market in 2006, religious conservatives decried the government's approval of the vaccine as implicitly sanctioning teen sex and encouraging promiscuity while advocates applauded its potential to prevent 4,000 cervical cancer deaths in the United States each year. Families worried that laws requiring vaccination reached too far into their private lives. Public health officials wrestled with concerns over whether the drug was too new to be required and whether opposition to it could endanger support for other, widely accepted vaccinations. Many people questioned the aggressive marketing campaigns of the vaccine's creator, Merck & Co. And, since HPV causes cancers of the cervix, vulva, vagina, penis, and anus, why was the vaccine recommended only for females? What did this reveal about gender and sexual politics in the United States? With hundreds of thousands of HPV-related cancer deaths worldwide, how did similar national debates in Europe and the developing world shape the global possibilities of cancer prevention? This volume provides insight into the deep moral, ethical, and scientific questions that must be addressed when sexual and social politics confront public health initiatives in the United States and around the world. © 2010 The Johns Hopkins University Press. All rights reserved.
Perhaps more than other medical technologies, vaccines-invasive processes whose benefits emerge through counterfactual reflection on the absence of disease-condense and highlight relationships of trust or skepticism between the state and its citizens and subjects. So it is not surprising that across the globe, wherever the prospect of human papillomavirus vaccination has been raised as a possibility, it has brought to the surface nascent debates about governance and control-about the troublesome relationship between government, big capital, adolescent girls, and the family, and about issues of sexuality and social control. These debates over HPV and the cervical cancer vaccines frame a challenge with multiple ironies. As one American policymaker noted, the vaccine "encapsulates so many issues that are at the core of politics and health policy right now." 1 In what follows we consider the possible introduction of HPV vaccines to compare issues of skepticism and pharmaceutical governance in the United States and various sites in Africa. In contrasting the po liti cal complexities surrounding the potential introduction of a single technology in one region of the largely privileged global North and one region of the largely resource-poor global South, po liti cal economy and epidemiological realities of contemporary. © 2010 The Johns Hopkins University Press. All rights reserved.
The advent of human papillomavirus vaccines such as Gardasil and Cervarix-vaccines designed to interrupt transmission of a sexually transmitted infection in order to prevent the development of cancer-holds enormous public health significance. But these developments also provide insight into central aspects of po liti cal life by demonstrating the complex interplay among biopolitics, biomedicalization, and the often bitterly fought politics of sexuality in the presentday United States.1 We address this interplay by examining an apparent contradiction suggested by the case of Gardasil, in light of episodes in the politics of science and the politics of sexuality during the presidential administration of George W. Bush. © 2010 The Johns Hopkins University Press. All rights reserved.
The licensure of Gardasil in June 2006 set off a flurry of legislative activity as states around the country took steps to maximize the benefits of the product among their populations. States select from a variety of policy approaches to increase uptake of a vaccine. They can sponsor educational and promotional efforts through mass media or in clinical settings; allocate public funds to pay for the vaccine; require that private insurers doing business in the state reimburse it; or require or allow schools to provide education about it as part of health curricula or other science units.1. © 2010 The Johns Hopkins University Press. All rights reserved.
Given the difficulty of confronting the fundamental social and environmental causes of disease, vaccines stand out as a supposedly simple solution, and they are widely acknowledged to be our best means of disease prevention. Modern history is replete with vaccine success stories, and vaccines have obvious appeal in a world of growing health threats. Yet, as Laura Mamo, Amber Nelson, and Aleia Clark write in chapter 7, vaccines are not neutral entities but rather sites of "cultural, social, and po liti cal contestation." As magic bullets promising intangible benefits against uncertain future perils, they inevitably provoke extreme responses: an optimism that can verge on fantasy and a skepticism that can carry over into rejection. When threats target particular segments of the population and are not perceived to be imminent, the push for vaccination may seem especially troublesome-giving rise to much cultural anxiety and sociopo liti cal debate. If vaccines are a loaded topic, so too are sexually transmitted infections, which have long operated as both dense signifiers and material manifestations of our complicated sexual politics. This doubly charged combination of the complexities of vaccination and those of sexuality describes the human papillomavirus. © 2010 The Johns Hopkins University Press. All rights reserved.
This book examines the social, economic and political issues of public health provision in historical perspective. It outlines the development of public health in Britain, Continental Europe and the United States from the ancient world through to the modern state. It includes discussion of: * pestilence, public order and morality in pre-modern times * the Enlightenment and its effects * centralization in Victorian Britain * localization of health care in the United States * population issues and family welfare * the rise of the classic welfare state * attitudes towards public health into the twenty-first century.
Located outside New York City, Ellis Island served as the most successful immigration processing station for six decades, until 1954, when the federal government closed it for good.1 History keeps ambivalent records of the place, which, in keeping with incomers’ experiences, is remembered as the “Isle of Hope,” the “Isle of Tears,” and the “Heartbreak Island” (Kraut, 53). For aspirers to the American dream, the immigration station signified the fear of disease and expulsion. For American citizens, however, Ellis Island confirmed the vitality and attraction worldwide of the American dream, even as it secured national borders against unwanted incomers. In its dual role as national symbol and immigration buffer, Ellis Island is reminiscent of the eternal antagonism in U.S. history between the national celebration of immigrant origins and the desire to exclude certain immigration groups. Whichever way the historical balance might tilt, it is certain that Ellis Island, as the first and largest processing station in the United States, cleared the way for the later inspection site of Angel Island, opened in 1910 for Chinese immigrants, and for the notorious El Paso border delousing practices. Ellis Island marks one more sequel in the long chain of U.S. integrationist policies, not unlike other state projects, all characterized by the attempt to define and delineate the form and content of the ideal nation.
The nation-state has long been theorized in terms of language, gender, race, and ethnicity, but there has been scarce attention given to the ideals of ablebodiedness underlying nationalist projects. Similarly, immigration, itself the focus of nationalist policies, has benefited only recently from an intersectional approach inclusive of disability. Any nation, its imaginary community notwithstanding, relies for its ideological survival not only on linguistic, gender, and racial uniformity but also on entrenched ideals of health and ability. Despite the close ties between ableism and nationalist policies and despite the fact that foreignness has been constantly medicalized as a contagious threat to the nation-state, only a handful of scholars interrogate from a disability studies perspective the nation-state’s demand for flawless bodies and minds. The present study on Ellis Island is an attempt to situate theories of nationality within a framework informed by disability studies. Ellis Island represents, I contend, an institutionalized discourse that promotes the ideal nation-state at the expense of the disabled and diseased alien bodies on the island.
According to Etienne Balibar, the nation is an ideology that survives through invented narratives of stable territories, generational continuity, and “fictive ethnicity.” Balibar provides an insightful account of national ideologies, but he overlooks the most pervasive ideological fabrication underlying any nation-state—the ideology of ablebodiedness. From a disability studies perspective, Ellis Island functions to remap the ideological underpinnings of the American nation according to ideals of health and ability. Moreover, an intersectional analysis of the immigration policies enforced on Ellis Island with an emphasis on disability would further complicate the Balibarian theory of the nation-state. My goal here, following Balibar’s notion of fictive ethnicity, is to propose the idea of fictive ability, a concept designed to examine the role that ableist values play in immigration policies generally and in Ellis Island immigration regulations particularly.
Fictive ability as an ideology contains human bodies within a public health system, confining individuals to a coherent narrative of ablebodiedness that undergirds national communities. Like other social identities, ability is a sociohistorical construction that functions to differentiate, marginalize, and control individuals under the aegis of the nation’s well-being. In public parlance, however, ability is conceived as anything but a social fabrication. Current scholarship stresses the social construction of race, gender, and sexuality, but theoretical efforts to demystify the ideology of ablebodiedness, though growing in number, have not yet gained wide acceptance in academic discourse. Fictive ability, then, represents an effective state ideology that not only sets up its own hierarchical system but also lends support to oppressive structures of class, gender, race, and sexuality.
To this point, both immigration and public health scholars have addressed rather successfully the multilayered interactions between public health institutions and immigrant groups. In particular, scholars in immigration studies constantly cross disciplinary boundaries in the attempt to understand...
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Epidemic disease, like war, is the health of the state. Since the dawn of the American Republic, state and local governments have wielded powers both plenary and plentiful to defend the people against smallpox, yellow fever, cholera, and other pestilences. Individual liberty and property rights melted away before the state's power—indeed its inherent legal duty—to protect the population from peril. Under the broad authority of the police power, state and local governments in the nineteenth century confined suspected disease-carriers against their will, established armed quarantines on land and at sea, seized private homes for smallpox pest houses, and enacted, in the approving words of the U.S. Supreme Court, “health laws of every description.”
Under current United States law, female immigrants between the ages of 11 to 26 must receive a six-month course of the Gardasil vaccine - one of the most expensive and controversial vaccines on the market to date - prior to becoming permanent residents and, eventually, naturalized citizens. This mandate does not apply to female United States citizens (or to male immigrants or male United States citizens). Moreover, before August 2008, female immigrants would have had to satisfy the same requirements as their male counterparts to obtain a 'Green Card.' This Article provides an overview of the development and use of the Gardasil vaccine, examines, from an international law perspective, the problems raised by the requirement that all female immigrants between the ages of 11 and 26 who are seeking permanent resident status receive Gardasil vaccinations, and argues that the Gardasil vaccine must be reclassified by the Centers for Disease Control and Prevention ('CDC'), or, more correctly, by the Advisory Committee on Immunization Practices ('ACIP'), so that the vaccine stops being a mandatory part of female immigrants’ process of obtaining permanent residency (and naturalization) status.
BACKGROUND
African-American (AA) women have lower survival rates from cervical cancer compared with white women. The objective of this study was to examine the influence of socioeconomic status (SES) and other variables on racial disparities in overall survival among women with invasive cervical cancer.METHODS
One thousand thirty-six women (705 white women and 331 AA women) who were diagnosed with primary invasive cancer of the cervix between 1988 and 1992 were identified through the Metropolitan Detroit Cancer Surveillance System (MDCSS), a registry in the Surveillance, Epidemiology, and End Results (SEER) database. Pathology, treatment, and survival data were obtained through SEER. SES was categorized by using occupation, poverty, and educational status at the census tract level. Cox proportional hazards models were used to compare overall survival between AA women and white women adjusting for sociodemographics, clinical presentation, and treatment.RESULTSAA women were more likely to present at an older age (P < .001), with later stage disease (P < .001), and with squamous histology (P = .01), and they were more likely to reside in a census tract categorized as Working Poor (WP) (P < .001). After multivariate adjustment, race no longer had a significant impact on survival. Women who resided in a WP census tract had a higher risk of death than women from a Professional census tract (P = .05). There was a significant interaction between disease stage and time with the effect of stage on survival attenuated after 6 years.CONCLUSIONS
In this study, factors that affected access to medical care appeared to have a more important influence than race on the long-term survival of women with invasive cervical cancer. Cancer 2008. © 2008 American Cancer Society.
Recent interest in human papillomavirus (HPV)-associated cancers and the availability of several years of data covering 83% of the US population prompted this descriptive assessment of cervical cancer incidence and mortality in the US during the years 1998 through 2003. This article provides a baseline for monitoring the impact of the HPV vaccine on the burden of cervical cancer over time.
Data from 2 federal cancer surveillance programs, the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries and the National Cancer Institiute's Surveillance, Epidemiology, and End Results Program, were used to examine cervical cancer incidence by race, Hispanic ethnicity, histology, stage, and US census region. Data from the CDC's National Center for Health Statistics were used to examine cervical cancer mortality by race, Hispanic ethnicity, and US census region.
The incidence rate of invasive cervical cancer was 8.9 per 100,000 women during 1998 through 2003. Greater than 70% of all cervical carcinomas were squamous cell type, and nearly 20% were adenocarcinomas. Cervical carcinoma incidence rates were increased for black women compared with white women and for Hispanic women compared with non-Hispanic women. Hispanic women had increased rates of adenocarcinomas compared with non-Hispanic women. The South had increased incidence and mortality rates compared with the Northeast.
Disparities by race/ethnicity and region persist in the burden of cervical cancer in the US. Comprehensive screening and vaccination programs, as well as improved surveillance, will be essential if this burden is to be reduced in the future.
The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends human papillomavirus (HPV) vaccination of 11- to 12-year-old girls, with catch-up vaccination for girls and women aged 13 to 26 years. Although compulsory HPV vaccination is not currently mandated for any U.S. population, immigrant women aged 11-26 years are now required to receive the first injection of the vaccine (the full series consists of three doses) as a result of the 1996 Illegal Immigration Reform and Immigrant Responsibility Act. According to this law, immigrants applying for visas to enter the United States or to adjust their immigration status must receive the inoculations that the Advisory Committee on Immunization Practices recommends for U.S. residents. In the case of HPV, this law represents not only an undue burden on immigrant women, but also raises scientific and ethical questions regarding the benefit of vaccination in this population. Given these issues, immigrant women should not be required to provide documentation of HPV vaccination at the time of visa application or adjustment of immigration status.
With Inclusion, Steven Epstein argues that strategies to achieve diversity in medical research mask deeper problems, ones that might require a different approach and different solutions. Formal concern with this issue, Epstein shows, is a fairly recent phenomenon. Until the mid-1980s, scientists often studied groups of white, middle-aged menâand assumed that conclusions drawn from studying them would apply to the rest of the population. But struggles involving advocacy groups, experts, and Congress led to reforms that forced researchers to diversify the population from which they drew for clinical research. While the prominence of these inclusive practices has offered hope to traditionally underserved groups, Epstein argues that it has drawn attention away from the tremendous inequalities in health that are rooted not in biology but in society. âEpsteinâs use of theory to demonstrate how public policies in the health profession are shaped makes this book relevant for many academic disciplines. . . . Highly recommended.ââChoice âA masterful comprehensive overview of a wide terrain.ââTroy Duster, Biosocieties
To better understand national patterns of invasive cervical cancer (ICC) incidence by race and ethnicity in order to develop appropriate ICC prevention policies.
Age-adjusted and age-specific ICC incidence rates were calculated by combined race/ethnicity, making distinct the Hispanic/all races category from three other Non-Hispanic (White, Black and other) racial categories.
There was a significant downward trend in ICC incidence during both time periods for every combination of race/ethnicity (p-value <0.05) except Hispanic/all races during 1995-1999. Non-Hispanic/Black and Hispanic/all races women had significantly higher incidence rates of ICC compared to Non-Hispanic/White women. ICC incidence peaked much earlier for Non-Hispanic/White women (35-44 years of age) compared to any other racial/ethnic group. Non-Hispanic (White, Black and other) women had lower rates of adenocarcinoma and squamous cell carcinoma compared to Hispanic/all races women. Non-Hispanic/Black and Hispanic/all races women were more likely to be diagnosed at late stage or unstaged at diagnosis than Non-Hispanic/White women.
Although ICC incidence decreased significantly over the last 10 years, Black or Hispanic US populations continue to have the highest ICC incidence compared to Non-Hispanic/Whites, highlighting the need for improved health literacy and social support to ensure their equal access to ICC screening and HPV prevention including HPV vaccination.
This paper takes a critical look at progress and prospects regarding the sociology of pharmaceuticals over the years. Key themes examined include: (i) medicalisation and pharmaceuticalisation; (ii) regulation; (iii) consumption and consumerism; (iv) expectations and innovation. Papers in the monograph are also introduced and discussed in relation to these themes. The paper concludes with some further comments and reflections on progress and prospects in this field, emphasising the continuing importance of sociological engagement with these personal and political issues in the 21(st) century.
D uring the 20th century the united states witnessed sweeping social, political, and economic transformations as well as far‐reaching advancements in medical diagnosis and care. Despite the dramatic changes in demography, the meaning of citizenship, and the ability to treat and cure acute and chronic diseases, foreigners were consistently associated with germs and contagion. In this article we explore why, at critical junctures in American history, immigrants have been stigmatized as the etiology of a wide variety of physical and societal ills. Anti‐immigrant rhetoric and policy have often been framed by an explicitly medical language, one in which the line between perceived and actual threat is slippery and prone to hysteria and hyperbole.
Our examination focuses on three periods of immigration history: (1) the late 19th century to the passage of the National Origins Act in 1924 when millions of newcomers arrived in the United States and increasingly stringent quotas were enacted; (2) an era of retrenchment and exclusion from 1924 to 1965 when far fewer immigrants entered yet their identification with disease and contamination remained intact; (3) and the period from 1965 to the present, when family reunification laws became the centerpiece of immigration policy and spawned the migration of millions of Asians and Latin Americans to this country.
During the 20th century the United States witnessed social, political, and economic transformations as well as advancements in medical diagnosis and care. Despite changes in demography, the meaning of citizenship, and the ability to treat and cure acute and chronic diseases, foreigners were consistently associated with germs and contagion. This article explores why, at critical junctures in American history, immigrants have been stigmatized as the etiology of a variety of physical and societal ills. The article analyzes three periods from 1880 to the present and suggests that now, as germs progressively and, often, indiscriminately cross national, social, and economic boundaries through multiple vectors, the mistakes of the past must not be repeated. Protecting the public health in the current era of globalization requires an ecumenical, pragmatic, and historically informed approach to understanding the links between immigration and disease.