Aging, Immigration and Justice

By Lisa Eckenwiler

The recent World Health Organ­ization (WHO) Report on Global Aging, which reconceptu­alized aging around “functional abilities” and situated it within a public health framework, put forward an urgently needed and ethically transformative vision of healthy aging: hav­ing “functional abilities to be and do what an older person has reason to value.”
This vision is grounded in social and global justice, taking the view that justice requires social sup­port to create conditions that nurture people’s capability to be healthy, to maintain affiliations, to exer­cise autonomy and to be mobile. WHO’s platform moves decidedly away from a biomedical model of aging, instead emphasizing the social determinants of health.
Immigrant Caregivers Play Essential Role
The care relationships surrounding aging people may be the most essential elements in supporting their functional abilities and capabilities for being healthy. Family caregivers are at the forefront, but the direct care workforce is integral—a labor force composed increasingly of immigrants, especially women, who fill long-standing shortages in this high-risk, low-paying labor sector that helps to sustain the burgeoning aging population.
As much as 28 percent of the home health workforce is composed of immigrant women. Global interdependence, specifically longtime connections between source countries and their migrants and destination countries and their older adults, are key to the structure of long-term care and to older people’s health. Immigration policy should be considered among other determinants of health such as economic and food security, a navigable, nurturing environment and fair wages and working conditions for direct care workers.
In this landscape, what are like­ly implications of the present action and rhetoric on immigra­tion, including the Reforming American Immigration for a Strong Economy (RAISE) Act and President Trump’s travel ban (with the latter now taking partial effect, given the recent ruling of a federal appeals court in California)?
If successful, the RAISE Act could pose barriers to less educated and skilled workers, many of whom take jobs in long-term care, ranging from housekeepers and dietary aides to certified nurs­ing assistants and licensed practical nurses. In such a hostile and uncertain context, some migrants may be reluctant to either travel to or relocate permanently to America. Those en route may con­front delays in processing documents and potentially face additional expenses.
Those already in the United States, especially the estimated 20 percent of home­­care workers who are undocumented, face fear, social isolation and uncertainty. As many as one out of five Deferred Action for Childhood Arrivals (DACA) beneficiaries reportedly work in and-or are pursuing edu­cation in healthcare occupations such as home health aides and nursing assistants. Deportation fears can erode and threaten current and future long-term-care delivery.
In thinking about care relationships around aging people, implications for family caregivers also figure prominently. A global outlier, the United States offers scant family leave policies for people in the paid labor force; this forces family caregivers to navigate a complicated terrain of work, care and other responsibilities, and experience heightened health and financial security risks. A climate of fear among the paid care workers that families often rely upon for homecare or residential long-term care can compound families’ concerns and diminish their ability to provide care.
In Pursuit of an Ethical Path
Perhaps such fear and anxiousness will encourage policy makers to reflect upon what constitutes an ethical posture toward the long-term-care workforce—especially the growing number of migrant workers. From an ethical perspective, U.S. policy has room to evolve, and there are three paths that America could pursue.
There could be a self-sufficiency model, which would require substantial national investment to expand domestic education and training capacities. Self-suff­­iciency would mean encouraging other countries with aging populations that need long-term care to build policies that will engage, train and boost employment for long-term-care workers, and be based on those countries’ needs. This strategy could keep care workers where they are needed (albeit often with inadequate re­sources). This model, however, might be unrealistic and wrongly restrict people’s freedom of choice to immigrate.
Investments in reciprocity and compensatory justice in immigrants’ home countries would be ap­propriate, as these countries have subsidized the education of the migrant U.S. care workforce (i.e., in the Philippines and in countries in Central America, Asia, the Caribbean and Africa).
Another strategy would be to continue relying upon a migrant long-term-care workforce, but be more ethical about doing so. This strategy starts with acknowledging our interdependence, espe­cially the global scale of our care relationships (across the life span). Nurses educated in low- and middle-income countries have served in U.S. hospitals and other care settings for some time in response to policies formulated mostly by international lenders and governments. They, and many others with less education and training, form a growing part of a much needed but deeply under­valued workforce, with some, especially homecare workers, enduring precarious social, economic and health conditions.
Meanwhile, people in source countries that have aging populations, along with high burdens of disease and an inadequate supply of health workers, often suffer under health inequities. America could be more ethical by better appreciating the asymmetries in resources and power—the global inequities—that underlie the aging of people around the world and create the context that com­pels, and in some cases, educates and prepares, care workers to migrate from poorer countries.
Ethical action would include commitments not to recruit workers from countries with health worker shortages, and to find policy levers to put these commitments to use in the long-term-care private sector, where for-profit players proliferate. Other strategies would be to create a path to citizenship for undocumented care workers (given their considerable social and economic contri­butions) and to develop programs to improve working conditions for migrant care workers, espe­cially in home care. Such reforms would support fairness and autonomy for care workers and re­duce the U.S. contribution to global health inequities.
Finally, America could undertake comprehensive reform that recognizes the interdependence and inequities between countries; this awareness would in­form the ethical foundation for enacting WHO’s vision for global aging. Social and global justice reforms can directly influence provision of the social bases necessary to assist those who care for aging people and to improve the “habitats” in which they dwell. These social bases include immigration and human health resource policies, equitably conceived and coordinated on a transnational scale.
Justice for both aging people and for care workers everywhere is inextricably linked on any charted course. Where countries lack the capacity to engage in coordinating ethical, comprehen­sive long-term-care policies, other nations and the WHO must step in to lead. 
Lisa Eckenwiler, Ph.D., is associate professor of Philosophy in the departments of Philosophy and Health Administration and Policy at George Mason University in Fairfax, Va. She is the author of Long-term Care, Globalization, and Justice (Baltimore, Md.: Johns Hopkins University Press, 2012).
Editor’s Note: This article appears in the January/February 2018 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.