1 article( title: ‘I like to protect my protector’: How US‐born Latinos

1 article( title: ‘I like to protect my protector’: How US‐born Latinos safeguard the livelihood of their immigrant communities from immigration enforcement encounters, author: Pinedo, Miguel; Rivera, Jazmin R.)

Immigration enforcement policies have been linked to poor physical and mental health outcomes among immigrant communities in the United States (US) (Bruzelius & Baum, [ 4]; Hatzenbuehler et al., [14]; Lopez, [16]; Martinez et al., [20]; Raymond‐Flesch, [31]; Viruell‐Fuentes et al., [37]). This is concerning given that in recent years, and especially during the Trump administration, there has been an exponential increase in punitive immigration policies, anti‐immigration rhetoric, immigration raids, detentions and deportations (Gonzalez, [12]; Lopez, [17]; Papakyriakopoulos & Zuckerman, [25]; Pinedo & Valdez, [30]; Raymond‐Flesch, [31]). For example, the Trump administration expanded the focus from deporting immigrants with criminal convictions to all immigrants regardless of prior criminal history, increased the number of Immigration and Customs Enforcement (ICE) officers, doubled the number of worksite immigration raids and sought to penalise immigrants receiving public benefits by making them ineligible for lawful permanent residency (Department of Homeland Security, [10]; Lopez et al., [18]; Pinedo & Valdez, [30]; Raymond‐Flesch, [31]). These policies helped to create a hostile anti‐immigrant climate by perpetuating, facilitating and exacerbating feelings of xenophobia, stigma, discrimination, harassment and violence towards immigrants (Armenta, [ 2]; Misra et al., [22]; Papakyriakopoulos & Zuckerman, [25]; Szkupinski Quiroga et al., [33]). Such circumstances also contribute to social isolation among immigrant communities who alter their daily routines to avoid public spaces and limit their visibility for fear of coming into contact with a law or immigration official, which would increase their vulnerability to being detained or deported (Benavides et al., [ 3]). For instance, immigrants who fear being deported commonly evade health and social welfare services (e.g. primary care, food pantries), do not report crimes (e.g. domestic abuse), avoid daily errands (e.g. going to the grocery store) and limit social activities (e.g. going to the park, going on neighbourhood walks, visiting family and friends; Benavides et al., [ 3]; Raymond‐Flesch, [31]; Vargas, [34]; Vargas & Pirog, [35]). Ultimately, these conditions produce intense fear and stress in the everyday lives of immigrants. Although immigration enforcement policies affect all immigrants regardless of race/ethnicity, it is imperative to recognise that immigration enforcement policies are highly racialised, and Latino immigrants bear a disproportionate burden. Latinos are the largest immigrant group and make up the largest portion of the undocumented population in the US (Budiman, [ 5]). As such, their collective risk for being detained and deported is greater than immigrants from other countries. ICE immigration raids also aggressively target Latino communities and workplaces known to have a high concentration of Latino workers (Benavides et al., [ 3]). Not surprisingly, the majority (>90%) of all immigrants who are deported from the US are of Latino‐origin (Pinedo, [27]). Relatedly, anti‐immigration rhetoric and attitudes have been closely linked with anti‐Latino sentiments. In other words, negative political and public sentiments against immigrant communities are primarily fueled by negative perceptions against Latinos as a whole, irrespective of immigration status (Pinedo et al., [28]). These sentiments add to the increasing hostility towards Latino immigrants, which then trickle down to their health. A substantial body of research has underscored the role that immigration enforcement policies and immigration‐related stressors play in shaping the health and health behaviours of Latino immigrants, including poor physical health, mental health status and substance misuse (Benavides et al., [ 3]; Lopez, [16]; Misra et al., [22]; Raymond‐Flesch, [31]; Viruell‐Fuentes et al., [37]). Notably, social support is an important source of resiliency among Latino immigrants that helps to buffer the negative impacts of immigration‐related stressors (Benavides et al., [ 3]; Bulut & Gayman, [ 6]; Lee et al., [15]; Lopez, [16]; Sanchez et al., [32]). In general, social support has been strongly associated with improved health outcomes across diverse populations, including immigrants. Social support can be characterised into four different types: ( 1) instrumental (e.g. providing tangible help and services); ( 2) informational (e.g. advice, suggestions); ( 3) emotional (e.g. expressions of empathy, love, affection) and ( 4) appraisal (e.g. information that is useful for self‐evaluation; Veiel, [36]). Research studies among Latino immigrants have reported on multiple ways in which immigrants provide social support to protect their communities from immigration enforcement activities. Sources of social support include, but are not limited to, providing transportation and linguistic services (instrumental support); disseminating information regarding ICE activities and raids, especially via social media (informational support) and providing words of encouragement (emotional support), among other activities (Benavides et al., [ 3]; Bulut & Gayman, [ 6]; Lopez, [16]; Pinedo et al., [28]; Sanchez et al., [32]). Social support is used as a means to cope with or buffer stressors stemming from immigration enforcement policies. Though much work has investigated social support in Latino immigrant communities, little research has specifically focused on the role that US‐born (i.e. non‐immigrant), adult, Latinos play in providing social support to their immigrant counterparts, especially during a time of heightened anti‐immigrant social and political climate. Our study aims to extend the existing literature by addressing this scientific gap using qualitative methods.

2 articles ( title: Deportation of Family Members of US-Citizen Latinos and Misuse of Prescription Drugs: United States, 2019. author: Pinedo, Miguel)

Objectives. To investigate how personally knowing a deported migrant relates to past-year prescription drug misuse among US-citizen Latinos. Methods. Between April and May 2019, a national sample (n = 3446) was recruited to complete an online survey. Multivariate and multinomial logistic regression models examined the role of ( 1) personally knowing a deported migrant and ( 2) the relationship to the deportee (e.g., family, friend) on ( 1) any past-year prescription drug misuse and ( 2) the frequency of prescription drug misuse. I limited analyses to US citizens only (n = 3282). Results. Overall, 19% of all participants reported any past-year prescription drug misuse. Latinos who had a family member who was deported reported significantly higher odds of past-year prescription drug misuse and were exceedingly at higher risk for misusing prescription drugs 3 or more days in the past year as compared with Whites and Latinos who did not personally know a deported migrant. Conclusions. Public health prevention strategies and deportation policies need to consider and address how the deportation of an individual will affect the health of that individual’s US-citizen family members. Prescription drug misuse has emerged as a critical public health concern in the past decade. Prescription drugs refer to opioids (i.e., pain relievers), tranquilizers, stimulants, or sedatives and do not include over-the-counter drugs. The misuse of prescription drugs is characterized as their use without having a prescription, recreationally (i.e., “just for the feeling”), or in greater amounts, more often, or longer than prescribed. According to national estimates, in 2017, approximately 7% of the total adult US population reported past-year misuse of prescription drugs.[ 1] This prevalence is significantly higher among young adults: 14% of those aged 18 to 25 years reported misusing prescription drugs in 2017. Importantly, this prevalence varies by race/ethnicity. Among those aged 18 to 25 years in 2017, 18% of Whites, 10% of Blacks, and 12% of Latinos reported past-year misuse of prescription drugs.[ 1] Although Latinos tend to report less misuse of prescription drugs, other studies have documented an elevated prevalence compared with the general population. For instance, a study among Latinos in Texas border communities found that past-year prescription drug misuse ranged from 7% to 26% among Latinos, depending on gender and border community.[ 2] Similarly, a national study among adults aged 65 years or older found that Latinos had 3 times the odds of misusing prescription drugs in the past year compared with Whites.[ 3] Prescription drug misuse carries numerous adverse health implications. The misuse of prescription drugs can lead to the development of prescription drug dependence, increase susceptibility to alcohol and other drugs, transition into injection drug use, and increase risk of HIV and other blood-borne infections and mortality stemming from an overdose.[[ 4]] These health consequences and implications are notably evident by the current opioid epidemic in the United States, which claimed the lives of more than 47 000 Americans through overdoses in 2017 alone.[ 9] It is not surprising that opioids are the most commonly misused prescription drug.[[ 9]] Furthermore, although opioid overdoses are highest among Whites, recent data have documented that opioid overdoses among Latinos are increasing at an exceedingly faster rate relative to Whites. For example, opioid overdose deaths among Latinos in Massachusetts doubled from 2014 to 2017.[11] This trend has also been observed nationwide. According to data from the Centers for Disease Control and Prevention, fatalities resulting from opioid overdose increased by 53% between 2014 and 2016 among Latinos.[12] However, why opioid overdose fatalities are increasing among Latinos is poorly understood. Much research has focused on understanding factors associated with prescription drug misuse, including sociodemographic characteristics, mental and substance use disorders, social factors (e.g., social norms, peer pressure, low social support), and contextual factors (e.g., physicians’ prescribing practices).[[ 2], [ 5], [13]] However, the role of structural-level factors and their influence on prescription drug misuse have received almost no attention. Specifically, within the context of Latinos in the United States, emerging findings from my research team have underscored the importance of deportations as a structural determinant of the substance-using behaviors of US-citizen Latinos. With use of current nationally represented data (2019), findings from this work suggest that US-citizen adult Latinos who have had a family member deported have significantly higher odds of reporting symptoms of a drug use disorder as compared with Whites.[16] The present study extends this previous work and is distinct in that this study exclusively examined the relationship between the deportation of family members and prescription drug misuse among US-citizen Latinos. The deportation of a family member is a traumatic experience that has an impact on the whole family unit who experiences multiple severe emotional and psychological stressors.[[17]] Such stressors may increase vulnerability to substance use, including prescription drug misuse. Over the past decade, the United States has heightened immigration enforcement efforts and reached historic levels of deportations. Since 2008, more than 3 million migrants have been deported from the United States. Most recently available data indicate that deportations remain high: more than 256 000 migrants were deported in 2017.[20] Importantly, Latino migrants make up the largest proportion of deportees. About 90% of all deported migrants are of Latino origin.[20] Given the increasing deportations of Latino migrants and increasing trends in prescription drug misuse, including increasing rates of opioid addiction and misuse, in the United States make this line of research timely and significant. The present study investigates the role of US-citizen Latinos’ relationship to the deported migrant on prescription drug misuse relative to other racial/ethnic groups and among Latinos only. METHODS This study draws on anonymous and de-identified data from the National Social Policy Survey. The original objective of the study was to better understand how social, political, and economic factors contribute to health and racial/ethnic health disparities. Between April and May of 2019, the National Social Policy Survey study team recruited 3446 adult participants of White, Black, and Latino racial/ethnic descent via e-mail invitations to complete an online survey. Participants were recruited by using contact information (i.e., e-mail addresses) from the national voter registration database and Web panels from Pure Spectrum and Cint, 2 market research firms. Briefly, Web panels entail registries of individuals who have agreed to partake in online surveys. Web panels are constructed through targeted invitations that are meant to reflect the general population. Web panels were used to reach nonregistered voters, including non–US citizens, to reduce bias. Next, participants were randomly selected and invited to participate via e-mail. While participants were recruited from different sources and sample vendors, they were collected simultaneously and deposited into a single uniform data set. A total of 6355 potential participants were invited via e-mail to complete the online survey. Of these, 5734 were eligible for the study, and 3446 participants agreed to complete the survey. Participants received no financial incentives. The final data set was weighted within each racial/ethnic group with the 2017 Census American Community Survey (ACS). Once all the data were collected, demographics characteristics were tabulated for each racial/ethnic group and compared with the ACS adult population. For each racial group, weights were added consecutively using a raking algorithm to balance the demographics to match the 2017 ACS overall adult population. The registered voter portion of the sample was derived from a different source to ensure that the respondents were registered to vote and could be verified on the voter file. Otherwise, they were randomly selected and had randomly distributed demographic characteristics much like the nonregistered portion. Measures The 2 dependent variables were ( 1) any prescription drug misuse and ( 2) the frequency of prescription drug misuse, in the past year. Participants were asked, “In the past 12 months on how many days did you use any prescription medications ‘recreationally’ (just for the feeling, or using more than prescribed)?” These questions were taken from the Substance Use Brief Screen scale.[21] Response options were ( 1) never, ( 2) 1 or 2 days in the past 12 months, or ( 3) 3 or more days in the past 12 months. Any prescription drug misuse is defined as engaging in prescription drug misuse at least 1 day in the past year (vs never). Frequency of prescription drug misuse was a 3-category variable based on the original question (i.e., never, 1 or 2 days, 3 or more days). The primary independent variable of interest was Latinos’ relationship to a deported migrant if they reported personally knowing someone who has been deported. Participants were first asked if they personally know someone who was deported. Those who answered yes were then asked to self-report if this was a family member, a friend, or a coworker or community member (participants were only allowed to choose 1 of these options and could not choose multiple answers). Using these data, I characterized participants into 6 mutually exclusive racial/ethnic groups: Whites, Blacks, Latinos who do not personally know someone who has been deported, Latinos who had a family member deported, Latinos who had a friend deported, and Latinos who had a coworker or community member deported. Important covariates included alcohol use disorder (AUD) and psychological distress. Both of these variables have been associated with prescription drug misuse.[14] AUD was measured with the Alcohol Use Disorders Identification Test-Concise (AUDIT-C), which has proven high sensitivity for detecting AUD.[22] This measure includes 3 items that ask participants how often they consume alcohol (never, monthly or less, 2 to 4 times a month, 2 or 3 times a week, or 4 times or more a week), how many alcoholic drinks they consume on a typical drinking day (1 or 2 drinks, 3 or 4 drinks, 5 or 6 drinks, 7 to 9 drinks, 10 or more drinks), and how often they consume 6 or more drinks on 1 occasion (never, monthly or less, 2 to 4 times a month, 2 or 3 times a week, or 4 times or more a week). A point is attributed to each response, ranging from 0 to 4. Scores are summed with a possible range between 0 and 12 points. A score of 4 or more for men and 3 or more for women is considered a positive screening for AUD.[22] The Patient Health Questionnaire (PHQ-4) was used to assess psychological distress. The PHQ-4 consists of 4 question-items that assess feelings of nervousness and anxiousness, uncontrollable worrying, disinterest or pleasure in doing things, and sentiments of depression or hopelessness. Participants self-reported the frequency of these sentiments in the past 2 weeks: not at all, several days, more than half the days, or nearly every day. A point is assigned to each response option (ranging from 0 to 3 points) and summed (total possible points: 12). A score of 3 or more is characterized as having psychological distress.[23] Important sociodemographic characteristics included age, biological sex, marital status, being US-born, highest educational attainment, employment status (full- or part-time vs unemployed), annual household income, and voter registration status (yes vs no). Finally, to assess for US citizenship, participants were first asked if they were born in the United States. Participants who answered “no” were asked they were a naturalized US citizen, have applied for citizenship, were a legal permanent resident, were a visa holder, or other. Participants who reported being US-born or naturalized US citizens were characterized as being US citizens. Statistical Analysis I weighted all statistical analyses to adjust for the sampling methods. I conducted analyses with Stata version 15 software (StataCorp LP, College Station, TX). Given the study’s objective, I restricted all analyses to US citizens and excluded non–US citizens (n = 164). I first employed descriptive characteristics for our sample, stratifying by race/ethnicity. Next, I conducted multivariate analyses to evaluate how race/ethnicity and Latinos’ relationship to deported migrants related to each outcome variable. For the dichotomous dependent variable, any prescription drug misuse, I estimated a logistic regression model. For the categorical dependent variable, frequency of prescription drug misuse, I estimated a multinomial logistic regression model. Both models controlled for sociodemographic characteristics and covariates. Finally, I replicated these models with only the sample of US-citizen Latinos to evaluate how Latinos’ relationship to deported migrants relate to each outcome, using Latinos who do not personally know a deported migrant as the comparison group. RESULTS Sample characteristics stratified by race/ethnicity are presented in Table 1. Overall, half the sample was male and they were on average aged 42 years. The majority were US-born and registered voters, though Latinos were the least likely racial/ethnic group to be registered to vote. White and Black participants were significantly more likely to report not personally knowing a deported migrant than were Latinos. Overall, 39% of Latinos in our sample personally knew someone who had been deported. Among Latinos, 17% had a friend who was deported, 10% had a family member who was deported, and 12% reported knowing a coworker or community member who was deported. In regards to prescription drug misuse, 19% (n = 666) of participants reported misusing prescription drugs in the past year. A higher proportion of Latinos and Blacks reported engaging in prescription drug misuse in the past year than of Whites. Latinos were also more likely to report psychological distress as compared with Whites and Blacks.

3 articles (title: Passport Biopsies: Hospital Deportations and Implications for Social Work

Author: Sullivan, John E. Zayas, Luis E.)

In the course of investigating barriers to health care in Arizona for Latino families as part of an MSW diversity class project, I happened upon a singularly daunting impediment to medical care: extralegal hospital deportations or the practice of returning uninsured, seriously injured or ill undocumented patients to their countries of origin. As a social work graduate student looking forward to a professional life centered in health care and immigration, learning of this practice was upsetting. This commentary brings some light to these interventions, which are privatized, lack state or federal policy guidance, and have far-reaching repercussions for undocumented patients and their families in Latino communities on both sides of the U.S. Southwest border. It also raises serious implications for social workers who must navigate institutional demands and clients’ rights when involved. There is a need for research and a heightened ethical awareness regarding the practice and consequences of hospital deportations, particularly when medical social workers and hospital caseworkers are charged with obtaining informed consent and facilitating the patient discharge process. OUT OF SIGHT, OUT OF BUDGET In stark relief to an already harsh immigration landscape in the United States, hospital deportation is a drastic discharge measure confronting uninsured, undocumented, hospitalized patients that warrants more attention because it entangles several important issues: immigration, critical illness care, lack of specific state regulation, overburdened hospital systems, ethics, and private subcontracting for repatriation (Devi, 2009; Dolgin & Dieterich, 2010; Johnson, 2009; Nessel, 2009). These pressing issues beset a doubly vulnerable population — the undocumented and critically ill — and certainly enter the purview of the social work profession. In the United States, 60 percent of adult noncit-izen and nonauthorized resident Latinos living in the United States have no health insurance; 37 percent of Latino adults within this group report having no habitual health care provider (Livingston, 2009). Hospitals that accept Medicare payments are required to treat any person seeking emergency care, as stipulated by the Emergency Medical Treatment and Active Labor Act (P.L. 99-272), and cover costs (with little chance of reimbursement) if patients are unable to pay or have no insurance (Dolgin & Dieterich, 2010). Unable to find long-term care facilities for undocumented immigrants in need, many hospitals are overwhelmed with the high costs of caring for the chronically ill in acute-care settings (Roberts, 2012). Faced with caring for undocumented patients needing long-term care, hospitals have found it economically advantageous to extrale-gally repatriate them to their (or their guardian’s) country of origin using private companies (Dolgin & Dieterich, 2010;Johnson, 2009; Sontag, 2008). MexCare is one such private company that carries out these repatriations and uses the business slogan “An Alternative Choice for the Care of the Unfunded Latin American National” (“Alternative Choice,” 2012; Sontag, 2008). Based in California, this company confirms making arrangements with certain hospitals in Latin America to provide care for repatriated patients but insists that patients have given full consent and have been moved voluntarily (Devi, 2009). Doubts have been raised regarding the accessibility, quality, and duration of needed medical treatment once these chronically or seriously ill patients are relocated internationally, including reports of reduced dialysis regimens and patient deaths in Mexico (Prez, 2010; Sack, 2010). The extent and frequency of medical deportations is exceedingly difficult to estimate because there are no governmental agencies tabulating these international transfers, much less regulating them (Sontag, 2008). Seton Hall University’s Center for Social Justice (2012) has estimated that there have been more than 800 cases of completed or attempted hospital deportations in the United States. Although by no means limited to Arizona and the U.S. Southwest Borderlands, reports hint at a more aggressive approach by hospitals in this region. According to Sontag (2008), St. Joseph’s Hospital in Phoenix repatriates some 96 immigrants each year; Vanderpool (2008) reported that University Medical Center in Tucson medically repatriates two to three patients per month. One case in particular illuminates the elevated risk for families of mixed immigration status: University Medical Center in Tucson attempted to forcibly repatriate Elliot Bustamente, an infant born with Down syndrome and a heart condition (Devi, 2009). A U.S. citizen, Elliot lived in Tucson with his parents, both undocumented immigrants. The repatriation was stopped at the last minute by police who “blocked the flight” (Sontag, 2008). NEBULOUS POLICY, CLEAR BORDERS Legal concerns regarding the infringement of patient rights have focused on the apparently ad hoc and private nature of hospital deportations and on the opaqueness of any guiding policy. Unsettled legal definition of these interventions has led to varied appellations, from medical transfer to forcible repatriation to medical rendition. Our use of the term “hospital deportation” draws from the literature (see Dolgin & Dieterich, 2010) and is based on an argument set forth by Johnson (2009) noting that the intervention is in effect a private deportation, albeit one without the trappings of due process; the patient is not afforded an appearance before an immigration judge or the right to appeal a decision, yet is ultimately removed from the country. Agraharkar (2010) has suggested U.S. hospitals may be involved in international “patient dumping” when sick patients are repatriated by way of bypassing (or lightly satisfying) federal guidelines regulating appropriate discharge of patients. Presumably, hospitals are relying on private companies to fulfill these discharge requirements, however tenuously. Widely used in the early 1980s, the terms “patient dumping” and “wallet biopsies” refer to the hospital practice of denying emergency care to certain patients (typically those without insurance or ability to pay) and moving them to another care facility before being properly stabilized. The wallet biopsies of decades past have been prohibited. But these extralegal cross-border medical transfers seem quite different; “passport biopsies” might be a more accurate representation. PATIENT ADVOCATE OR CLERICAL CONSORT? Medical social workers and hospital caseworkers find themselves at the nexus of administrative action and patient rights. Specifically in cases of hospital deportations, social workers may maintain critical contact with undocumented patients when obtaining informed consent and facilitating the discharge process. First of all, it is important to note that current research evaluating social workers’ awareness, degree of involvement, knowledge, and attitudes regarding such practice and its implications appears to be nonexistent. In light of media reports of social workers “badgering” chronically ill patients for the purpose of obtaining informed consent (Rice, 2011), this omission is unsettling (and untenable) given the predominance of intake, referral, and discharge duties shouldered by social workers in hospital settings. Reamer (1987) has outlined the following six criteria that must be satisfied in determining validity of consent: (1) An absence of coercion and undue influence must exist, (2) clients must be capable of providing consent, (3) clients must consent to specific procedures, (4) the forms of consent must be valid, (5) clients must have the right to refuse or withdraw consent, and (6) client decisions must be based on adequate information. (p. 426) This is a vital process, both legally and ethically, and hospital administrators along with private contractors have emphasized that they receive patient consent before repatriations (Devi, 2009; Sontag, 2008). Yet, is consent an “event” formally established by autonomous individuals, or a socially constructed “process-perceived, experienced, and shaped through interactions between individuals and their social contexts”? (Alderson & Goodey, 1998, p. 1315). Studies have found that Mexican Americans embrace a more collectivist model of medical decision making than the individualistic patient autonomy model (Blackhall, Murphy, Frank, Michel, & Azen, 1995) that hospitals in the United States follow in obtaining informed consent. Moreover, Agraharkar (2010) has advised special caution when establishing valid informed consent with patients who may be “particularly susceptible to coercion because they are often poorly educated, have limited knowledge of English, unstable or tenuous immigrations status, and have suffered catastrophic injuries” (p. 599). It is possible that some hospital social workers are unaware of the true nature of the repatriation or may genuinely believe patients will receive continued care in their country of origin, even if this may not be the case. Still, the weighty ethical obligations put upon social workers to fully understand the process and consequences of such hospital practice cannot be minimized, especially when honoring client self-determination and other ethical issues in the NASW Code of Ethics. Patients and their families frequently rely on social workers when faced with difficult medical decisions, looking for assistance “in their ethical reflection process” (O’Donnell et al., 2008). Sontag (2008) reported that some families of patients identified for deportation “accept that fate because they are told they have no options” (p. 3). When asked for consent, it is neither unthinkable nor uncommon for patients to turn the question back on allied health care professionals or defer outright: What should I do? Tell me what to do. Hartman (1993) has insisted that social workers “have been less ready to own that we, as professionals, are part of ‘the system’ and to examine the implications of our position of power” (p. 365). From this bearing, it is all the more distressing to read that a social worker at the University of Texas Medical Branch “badgered [an undocumented, paralyzed immigrant] about signing documents that would allow the hospital to purchase him a ticket for Mexico” (Rice, 2011, p. 1). The director of social work in Chicago’s Mount Sinai Hospital sketched out the international scope of repatriations: “We’ve done flights to Lithuania, Poland, Honduras, Guatemala, and Mexico” (Sontag, 2008, p. 2). A second key interaction between patients being repatriated and social workers occurs during the discharge process. Judd and Sheffield (2010) underscored the responsibilities of hospital social workers in arranging “post hospital care” and confirmed that “discharge planning continues to be a primary role for hospital social workers consuming the preponderance of their time” (p. 866). In seeking out signatures and collaborating with potentially illicit transborder discharges of seriously ill patients, the question arises: Are social workers being co-opted by questionable hospital policy and unwittingly tasked with de facto immigration enforcement duties? Parton and Kirk (2009) have argued that social work has long been concerned with both “care and control” noting that “for, while it attempts to liberate and empower those with whom it works, it also works on behalf of the state and the wider society in order to maintain social order” (p. 35). Social workers carrying out these duties may risk conflict of interest. Taking into account the ad hoc and sub-rosa haze in which hospital administrators and health professionals (including social workers) conduct hospital deportations, the validity of consent given by a gravely ill immigrant and the legality of the subsequent discharge to an international facility may be rightly questioned. Highlighting the potentially coercive milieu of financially burdened hospitals, the chief financial officer of University Medical Center in Las Vegas has acknowledged four instances in which his institution was “able to convince illegal immigrants” to accept continuing care in their countries of origin (Harasim, 2009, p. 2). Returning to MexCare’s branding motto, we are left to wonder if this “alternative choice” in health care provision is primarily the patient’s or the hospital financial officer’s. A CALL FOR ETHICAL GUIDANCE Although health care system administrators attempt to maneuver amid unfunded patients, federal regulations, and budgetary concerns, social workers may experience discomfort when forced to balance the agency practice of hospital deportations, job security, and ethical practice. O’Donnell et al. (2008) have studied ethical stress, job satisfaction, and the freedom of social workers to take “moral actions” in the workplace and noted that “organizational climate and the organizational resources available influence the likelihood of moral action” (p. 47). Professional social work organizations may wish to support the “moral actions” of those social workers confronting such a dilemma while concurrently advocating for undocumented hospital patients facing involuntary repatriation by following in the spirit of the American Medical Association (AMA); newspaper reports of hospital deportations drew consternation from some members and spurred the release of recommendations adopted by the AMA Council on Ethical and Judicial Affairs (2009) to address the issue, which included the following: Assist a patient who is unwilling to accept the discharge plan to seek independent ethics consultation or other means of resolving ongoing disagreement; and refrain from signing a discharge order that would result in involuntary discharge of a patient who is not a US citizen to his/her country of origin and advocate for the patient’s opportunity to seek formal review of the proposed involuntary removal from the US by appropriate government authorities. (p. 94) Future research — possibly informed by theories of consent, distributive justice, culturally empathetic practice, or organizational climate — might delve into how social workers should best navigate the process of hospital deportations. It is heartening to know that our profession values its patient advocacy role, but due to lack of awareness or disengagement with hospital policy and administrators, social workers may be disregarding professional codes, or worse, participating in extralegal medical deportations fraught with serious legal and ethical implications. However, the consequences for clients are graver yet.

4 article ( title: Rural Depopulation: Growth and Decline Processes over the Past Century. Author: Johnson, Kenneth M., Lichter, Daniel T)

This article highlights the rise and geographic spread of depopulation in rural America over the past century. “Depopulation” refers to chronic population losses that prevent counties from returning to an earlier period of peak population size. In this article, we identify 746 depopulating counties—mostly nonmetropolitan—representing 24 percent of all U.S. counties. More than 46 percent of remote rural counties are depopulating compared to 24 percent of the adjacent nonmetropolitan counties and just 6 percent of metropolitan counties. Rural county populations often peaked in size during the 1940s and 1950s, especially in the agricultural heartland. Depopulation today reflects a complex interplay of chronic net out‐migration and natural decrease that is rooted in the past. Depopulation not only is a direct result of persistent out‐migration but also reflects large second‐order effects expressed in declining fertility and rising mortality (usually associated with population aging). Depopulation has become a signature demographic phenomenon in broad regions of rural America.

The U.S. nonmetropolitan population peaked in 1940 at 75 million people, representing 57 percent of the total population (Gibson [11]). At that time, the majority of people lived in small cities and towns or in the open country. The 1940s marked a clear inflection point in America’s evolving settlement system. Rapid urbanization and population concentration had already been under way for decades by the 1940s, though it did slow during the Great Depression. After World War II, the 1950 decennial census revealed, for the first time, that the majority of all Americans lived in metropolitan counties. Burgeoning metropolitan growth and the urbanization of American society have dominated the nation’s population and economic trends ever since (Fuguitt [ 9]; National Advisory Commission on Rural Poverty [31]). Metropolitan growth has been fueled by natural increase, a substantial flow of rural‐to‐urban migrants, and new immigrants from abroad. Rural people and places have often been “left behind” in America’s evolving urban settlement system (Lichter and Ziliak [24]; Wuthnow [36]).

Today, rural America is once again at an important demographic transition point. The Census Bureau’s recent population estimates show that America’s nonmetropolitan population stood at only 46.1 million in July 2016, representing a new low of only 14 percent of the entire U.S. population (Economic Research Service [ 8]). Many nonmetropolitan counties, especially in remote rural areas, have been marginalized in an increasingly urban settlement system marked by ongoing shifts away from farming and other extractive industries and by the ascendancy of a globalizing economy. In the past, nonmetropolitan counties “left behind” by urban growth and sprawl still experienced modest population gains in the aggregate; net out‐migration historically was more than offset by natural increase—the difference between births and deaths. Today, nonmetropolitan counties are experiencing absolute population decline for the first time in America’s history. Between 2010 and 2016, nonmetropolitan counties declined by just over 190,000 people, representing a −0.4 percentage loss (Cromartie [ 5]). Population loss has seemingly become the new demographic norm across broad regions of rural America.

This article documents for the first time the genesis and evolution of rural depopulation over a long time horizon, from 1900 to 2016. For our purposes, “depopulation” refers to chronic population losses that prevent counties from returning to an earlier peak population. We define depopulation as occurring when a county reached its peak population by 1950 and then lost at least 25 percent of its peak population by 2010. Indeed, our data show that roughly one‐third of all nonmetropolitan counties have depopulated over the past century. We have three specific goals in this article. First, we highlight the emergence of depopulation as a demographic phenomenon in rural America, and trace its origins back to 1900. Second, we document the historically uneven spatial distribution and heterogeneity of population growth and decline processes across nonmetropolitan America. Third, we illustrate how chronic rural depopulation reflects a complex interplay historically of net migration and natural increase (or decrease). For an increasing number of nonmetropolitan counties, net out‐migration and natural decrease—now working in concert—have exacerbated the interdecadal pace of absolute population decline. As we document here, depopulation is unprecedented in geographic scope and magnitude.

Our analyses of rural depopulation highlights the extraordinary demographic and economic challenges now facing many nonmetropolitan areas of the United States. Our work is of particular relevance now when rural America has taken center stage politically (as a result of the 2016 presidential election) and has become linked in the public mind to the new “geography of despair,” which is marked by declining life expectancy, opioid and drug abuse, and chronic poverty and unemployment (Lichter and Ziliak [24]; Monnat and Brown [27]; Wuthnow [36]).

Rural Depopulation: Some Lessons on Growth and Decline Processes

Chronic population decline or depopulation has become a familiar pattern of population change in many low‐fertility countries around the developed world (Münz [28]; Nikitina [32]). Rural areas have “emptied out” as urbanization has continued apace throughout much of Europe and many east Asian countries. Long‐term industrial restructuring—away from agriculture and other extractive sectors—and the recent globalization of manufacturing are inextricably linked to the emergence and spatial diffusion of uneven long‐term trajectories of subregional growth and decline. The transformation of agricultural production over the past century clearly set into motion a series of long‐term demographic processes that have culminated in rural depopulation across much of the developed world. From an economic perspective, uneven population growth and decline over time arguably reflect processes of cumulative causation, whereby rapid and unprecedented economic and technological change has demographic consequences that reverberate unevenly throughout the entire settlement system, often at the expense of rural or underdeveloped periphery areas (Myrdal [29]; National Academy of Sciences [30]). Rural depopulation or the chronic loss of population is a cumulative demographic process that can be traced historically to specific components of demographic change: migration, fertility, and mortality.

The concept of depopulation suggests a withering away of small town and rural areas. Unlike in Europe, most U.S.‐based research has failed to address the topic of depopulation, invariably focusing separately on chronic patterns of rural net out‐migration (Johnson and Fuguitt [19]) and, more recently, on newly emerging patterns of natural decrease (Johnson [16]; Johnson and Lichter [20]). However, regional research examining linkages between rural population change and community banking has begun to explore how demographic forces are reshaping rural communities (Anderlik and Cofer [ 1]; Walser and Anderlik [34]). Though U.S. research on depopulation is limited, recent research in Europe and other developed countries, especially in east Asia, provides some rather clear demographic lessons about the etiology of depopulation, that is, how migration, fertility, and mortality work in concert to effect depopulation and diminish prospects for future growth (Münz [28]; Nikitina [32]).

In a recent article, Johnson, Field, and Poston ([18]) suggest that low fertility in Europe, coupled with the high mortality of an aging population, has raised the prospect of sustained and widespread depopulation. They place the spotlight on natural decrease. Fewer births and more deaths across Europe, combined with comparatively low rates of international migration, mean that local or regional growth is driven almost entirely by internal migration. By historical standards, natural increase in the United States today is very low (0.44 percent), but it still exceeds the rate of natural increase in all but four European countries (Johnson et al. [18]). Germany, Italy, Poland, Russia, and Japan are now experiencing natural decrease—more deaths than births (Doteuchi [ 6]; Haub and Kaneda [13]; Münz [28]; Nikitina [32]). South Korea will soon join this group of countries (Heo and Poston [14]).

These country‐specific patterns, however, mask the fact that depopulation today is distributed unevenly—at the subnational level—and experienced most acutely in rural areas (especially in remote areas far removed from metropolitan population and employment centers), reflecting decades‐long patterns of aging in place; below‐replacement fertility; and little, if any, immigration. In the context of low immigration, natural decrease rather than out‐migration is largely driving population decline in Europe and Asia (especially in Russia and Japan). In the United States, the overall incidence of natural decrease has increased rapidly (Johnson [16]), but nevertheless remains much lower than in Europe (e.g., 28 percent of U.S. counties vis‐à‐vis 58 percent of European counties experienced natural decrease between 2000 and 2010) (Johnson et al. [18]).

Out‐migration has characterized much of nonmetropolitan America over the past century, especially in counties dependent on agriculture, mining, and forestry. Recently, however, nonmetropolitan counties in the aggregate have experienced net out‐migration (Mayer, Malin, and Olson‐Hazboun [25]; McGranahan, Cromartie, and Wojan [26]). Between 2010 and 2016, for example, 462,000 more people left rural areas than moved in and the majority of nonmetropolitan counties experienced net out‐migration (Cromartie [ 5]). Moreover, both immigration from Mexico and Latin America and Hispanic fertility have slowed significantly since the recession of 2008–2009, reducing another historically significant source of rural population growth (Lichter [22]).

Unlike in the past, natural increase seemingly can no longer fully offset population losses from net out‐migration in many rural counties. The result is a growing incidence of natural decrease, marked by the excess of deaths over births. Fifty years ago, Calvin Beale ([ 2]) first identified natural decrease as an important dimension—an “emergent phenomenon”—of rural population decline. More recently, Johnson ([16]) revisited this issue, showing that a record number of U.S. counties (nearly 1,000) in 2002, mostly nonmetropolitan (over 90 percent), experienced an excess of deaths over births. Moreover, the majority of all nonmetropolitan counties (63 percent) experienced at least one year of natural decrease between 1950 and 2005. Recent evidence suggests even more widespread natural decrease. In 2012, the number of natural‐decrease counties reached a new high—1,135 or 36 percent of all counties (Johnson [17]). As never before, rural natural decrease is presumably now working in concert with chronic net out‐migration to exacerbate the loss of population in many nonmetropolitan counties.

Depopulation has become a demographic reality for many parts of nonmetropolitan America, and the prospect of depopulation is on the horizon for many more aging rural areas. The substantive implications are clear: To fully understand rural population dynamics today requires an appreciation of the historical interplay between net migration and natural increase. Protracted rural population losses are symptomatic of fundamental changes in the local population structure, especially low fertility and population aging, which ultimately reduce the prospect of population growth. Out‐migration is highly selective of young adults, leaving behind an aging‐in‐place older population that is increasingly unable to replace itself (Johnson and Winkler [21]). This combination of high mortality and low fertility is now firmly built into the age distribution of many declining rural places. The selective out‐migration of young adults over many decades has drained many nonmetropolitan counties of their demographic resilience by reducing the child‐bearing age population, thereby diminishing the prospect of regaining demographic equilibrium.

The Demographic Drivers of Depopulation

Depopulation provides an unusually clear indicator of the lack of demographic vitality, now and in the future. As we illustrate here, the prevalence, timing, and magnitude of depopulation in America have unfolded unevenly across the geographic landscape. As a harbinger of incipient population decline in a low‐fertility aging society, our study of rural depopulation sensitizes us to the complex interplay among the underlying demographic components of population change. Migration—both internal and international—and natural increase play out unevenly across the United States, with many rural areas arguably now serving as portent of things to come (Johnson and Lichter [20]). In the absence of new immigration, rural areas will remain on the front line of unprecedented population change, especially as natural decrease takes a demographic grip on many local areas with aging‐in‐place populations that have been depleted over the past century by chronic out‐migration of young adults of reproductive age. The demographic lesson is clear: Depopulation has accelerated over time across an increasingly broad swath of rural America.

Methodology

Data

We use counties as the unit of analysis. Counties are appropriate because they have historically stable boundaries and they are a basic unit for reporting fertility, mortality, and census data. There are 3,141 counties or county equivalents in the United States. Because of difficulties with boundary changes and historical data in Alaska and Hawaii, we limit our analysis to the continental United States.

Counties are classified by metropolitan status using data from the U.S. Office of Management and Budget. We use a consistent 2013 definition of “metropolitan” and “nonmetropolitan” throughout our analyses. As a result, several hundred counties that would have been classified as nonmetropolitan under previous Office of Management and Budget definitions are included in the metropolitan universe reported here. This highly selective reclassification process has, over the course of several decades, removed many fast‐growing counties from the universe of nonmetropolitan counties and reclassified them as metropolitan. Nonmetropolitan counties are further disaggregated by whether they are adjacent or nonadjacent to metropolitan counties using the 2013 rural‐urban continuum code and by the rural county typology developed by the USDA’s Economic Research Service ([ 7]). We use the terms “nonmetropolitan” and “rural” interchangeably in this article, as we do the terms “metropolitan” and “urban.”

County population data come from the decennial census for 1900 to 2010. Historical data on births, deaths, and migration for 1950 to 2010 are from the integrated age‐specific net migration files developed by multiple teams of demographers over the past 60 years (Winkler et al. [35]). Demographic data from 2010 to 2016 are from the Census Bureau Population Estimates Series. Estimates of net migration are derived by the residual method, whereby net migration is what is left when natural increase (births minus deaths) is subtracted from the total population change.

Measurement

There is no consensus on what constitutes depopulation. At a minimum, however, it reflects an absolute population decline of significant size over an extended period rather than an episodic or occasional decline. Our analysis of depopulation extends back to 1900, providing us with a long time frame to characterize specific countries as depopulating or not. For our purposes, county depopulation occurred if a county reached its maximum population by 1950 and had a population at least 25 percent below its peak population in 2010. The 1950 census is the first one following an era in which migration and fertility were constrained by the Great Depression and World War II. Dramatic demographic changes occurred in rural America after 1950, thus marking the boundary between two demographic eras. Although there is little consensus on what constitutes a significant loss of population, our preliminary analyses suggest that declines of 25 percent or more represent a substantial population loss with implications for the economic and social structure of counties.

Delineating the longitudinal pattern of depopulation is a unique aspect of our study. That is, does it occur in a linear or cumulative fashion? Does a county simply stop growing and start to decline? Or do counties lose population for a time, begin to grow again, and then fall back into decline? If so, which specific demographic components of population change—natural increase or migration—influence the process? Are some counties destined to decline, but then recover from it? If so, what causes the recovery? Given how little is known about depopulation, our study yields important new findings about the prevalence and dynamics of depopulation in both nonmetropolitan and metropolitan America.