Immigration as a Social Determinant of Health:
My research is guided by a central concern with the increasing significance of citizenship status within immigrant lives and communities. I explore these issues through ethnographic research amongst a socially similar group of children of immigrants—those in the undocumented 1.5 generation and their citizen born second generation peers. I highlight the deep cleavages that have emerged in a context where there has been a lack of comprehensive federal immigration reform since the Immigration Control and Reform Act of 1986. I explore how this “master status” operates in various domains in the day to day life of my informants including in education, employment, and (most significantly) health.
Immigration and health are two areas that are critical to public policy, important sites for political debate, and prominent subfields within sociology. However, the connections between them are often under-explored. My research addresses these key areas by examining issues that arise at the intersection of healthcare and immigration reform. There are serious health implications of immigration policies (or a lack of immigration policy), and my work addresses particular issues for both the undocumented and those living within mixed status families. These concerns are particularly pressing in the current historical moment, as fear and uncertainty in an increasingly anti-immigrant environment can intensify health disparities and lead to lower levels of healthcare access.
Qualitative Methods and Research on Health Equity:
Qualitative research can be used to identify processes within health disparities (specifically linked to those often captured in the “social determinants of health”) and in building conceptual models and hypotheses. They are particularly useful when applied to vulnerable and hard to reach populations including individuals living with precarious legal status. My research agenda is thus also centrally interested in utilizing and harnessing the enormous potential of qualitative methods. Doing so necessitates work that improves upon the rigor of qualitative methods in the interdisciplinary field of public health.
I see my research as developing in several key ways related to these interests. Specifically I will continue methodologic research that advances the transparency and power of particular kinds of qualitative approaches. First, I am interested in collaborating on work involving qualitative or mixed methods approaches and second through methodologic research that advances the transparency and power of particular kinds of qualitative approaches. With regards to the former, I am interested in assisting in logic of inquiry/research design issues for studies that evaluate implementation of interventions as well as providing expert assistance in constructing interview guides and in identifying potential research participants. Such collaborative work in implementation studies specifically can be used to reflect on processes of implementation while also including more theoretically driven work aimed at understanding implementation effectiveness and identifying mechanisms involved in change within interventions.
Finally, I will continue to conduct qualitative methodologic work that aims to build trust and rigor in how such methods are used and understood in medicine and public health more broadly. This will include studies on how “consensus” is established in team-based qualitative projects that involve coding as well as work that aims to bring transparency to the qualitative enterprise more generally. Future research will include studies on how “consensus” is established in team-based qualitative projects that involve coding and recommendations for best practices that again aims to bring transparency to the qualitative enterprise more generally. My goal ultimately will be to utilize my research to contribute to an established semantic consistency for other public health researchers interested in conducting similar future work.
PUBLICATIONS
Calvelli, Hannah, Olivia Duffield and Brian Tuohy. “Why medical students should learn about prison health"“, BMJ, 384 (2024)
Imprisonment is a global public health crisis that needs greater attention in medical education. Service learning is a potential way to close this gap in medical education, as it prioritises the lived experiences of people affected by imprisonment. Exposure to the realities of prison healthcare and its shortcomings are essential for medical students to understand and tackle the challenges of providing equitable care for this marginalised population.
Calvelli, Hannah, Olivia Duffield and Brian Tuohy. “Closing a Gap in Medical Education: Service Learning to Address Health Inequity in Prisons” Medical Education 57:11 (2023)
Despite efforts within medical education in recent years to increase awareness about health inequities, the prison population is often overlooked. The two million people incarcerated in the United States experience disproportionately high rates of chronic health problems, which are attributable to health inequities such as the inability to access medical care, failing prison infrastructure, unsafe conditions, and shortages of medical resources. Medical students receive limited exposure to prison health. When present, it is mostly limited to faculty-led didactics, which neglect the critical lived experience of those who are incarcerated and do not expose students to the harsh realities of the prison healthcare system. Our institution is located in Philadelphia, which has one of the highest incarceration rates in the country, yet there existed no means for educating medical students about prison health. This is a major gap in medical education that must be closed to ensure medical students have the knowledge and skills to meet the needs of this vulnerable population. We developed a novel student-driven service learning program in collaboration with Prison Health News, a non-profit organization that responds to letters from incarcerated individuals across the country seeking health information. Our program consists of 21 first-year medical student learners and two third-year medical student site leaders overseen by a faculty advisor from our Center for Urban Bioethics. Service learners are trained on letter writing, including finding reputable sources, writing for a lay audience, and practicing empathetic communication. Additionally, students participate in reflection sessions to elicit feedback, discuss emerging themes from letter writing, and learn about the state of the prison healthcare system. The site leaders serve as liaisons between the service learners and Prison Health News to coordinate the letter writing process.
Tuohy, Brian and Jillian Jatres. “Researching Those in the Shadows: Undocumented Immigrants, Vulnerability and the Significance of Research” American Journal of Bioethics (Open Peer Commentary, forthcoming)
In “IRBs and the Protection-Inclusion Dilemma: Finding a Balance,” Dr. Phoebe Friesen and her collaborators provide a compelling framework that helps Institutional Review Boards think through effective ways to find a balance between protecting research participants and including those who are underrepresented. In this OPC we build on the work of Friesen et al through examining one particular “vulnerable” group that has not been directly considered: undocumented immigrants. Doing so allows us to further critique the definition of vulnerability and expand on their argument that excluding such populations is an ethical failure through neglecting their experiences while also removing their access to possible benefits of research. Undocumented immigrants are an important and challenging example of a “vulnerable” population because their risk lies more in confidentiality than physical, mental, or autonomy matters. Owing to deportation fears, many undocumented immigrants desire to avoid public institutions or leave “paper trails” with bureaucratic institutions including hospitals and health systems. Through this case we build upon the protection-inclusion dilemma in several key ways: first, we explore how the designation of “vulnerability” applies to undocumented immigrants and what safeguards can be made to both protect and include them. Second, we argue that central guidance is needed to reduce the variability of how IRBs across universities and disciplines handle this population and provide suggestions to ensure more consistent ethical decisions around this group. Third, we recommend having trained IRB officials at all institutions capable of evaluating ethical questions associated with this population and training programs at graduate institutions offering current and future researchers the ability to do this kind of sound, ethical, and sensitive research. This will require a considerable overhaul at educational and institutional levels, and in our concluding section we build upon recommendations from Friesen et al that are tailored specifically to this population.
Healy, Megan and Brian Tuohy. “Trauma and Community: Trauma-Informed Ethics Consultation Grounded in Community Engaged Principles” American Journal of Bioethics (Open Peer Commentary, 2022)
Elizabeth Lanphier and Anani E. Uchenna provide a powerful argument for the value of a trauma informed approach to the ethics consultation, one which acknowledges the perspectives of all stakeholders to produce a more patient centered, healing and just resolution to complex clinical scenarios. This is a potentially critical intervention as the practice of medicine can be understood as largely trauma uninformed. In this OPC, we apply Lanphier and Uchenna’s framework to an urban, academic medical center for adult patients, which serves as a safety net institution for a structurally vulnerable community. This allows us to identify what we argue should be a key component of any TIEC model: namely, we must include community voice and hold community as an essential partner in ethical consultations. Doing so will show that the necessary tools and knowledge exist within communities themselves and should be recognized and elevated to achieve trauma-informed practice that is sensitive to structural determinants of health. Our piece further adds to the model by demonstrating the value of incorporating principles of community engagement to inform the planning, implementation, and evaluation of a TIEC service that is sensitive to historical context, including oppression and marginalization. We will offer examples of how to leverage an appropriately resourced community advisory board with power to direct meaningful change. This piece thus makes an argument for the need to incorporate community voices in ethical consultations while also positioning readers across disciplines to effectively advocate for and build a community engaged TIEC program that will better address the pressing need to move from trauma informed theory to praxis in the clinical setting.
Rocco, Providenza and Brian Tuohy. “A New Dawn of Bioethics: Advocacy and Social Justice”, American Journal of Bioethics (Open Peer Commentary, 2021)
Funding and academic acclaim favor traditional bioethics: a bioethics that is theoretical, medical, and, most critically, largely removed from social justice. This deficit is common--with only a handful of bioethics programs and scholars diving deeply into this work, and even fewer spearheading programs that confront social justice issues directly. Foundations, institutes, governments, academic health centers, and private donors should consider funding and supporting more programs that have direct and immediate impact on community members’ lives. In this OPC, we will describe a program led by a bioethicist in an urban medical school that focuses on dismantling food apartheid funded primarily through an alliance between a bioethics center and a hospital foundation whose priorities are focused on eliminating cost and access as barriers for food choice in neighboring communities impacted by structural and racialized inequities. This model can be replicated when bioethicists use their practical and clinical training to actively address other social justice issues such as gun violence or substance-use disorder, but that requires confidently shattering current funding priorities and conceptual limitations. In bioethics, the time is ripe for priority reform, and for funding sources to support population-level health concerns as steadily and fully as funding technological and traditional medical research. Bioethicists can and should take up this cause as crucial patient and community advocates, vital to the long-awaited movement of informed, compassionate, community-led, accurate, accountable, and actionable social justice.
Tuohy, Brian. “Health Without Papers: Immigrants, Citizenship and Health in the 21st Century” Social Forces. (2020)
Over the past several decades, citizenship status has become more important in immigrant lives and communities in the United States. Undocumented adults who arrived as children, the 1.5 generation, comprise a growing percentage of the immigrant population. Although they are similar to children of immigrants born in the United States (the second generation) they face a variety of barriers to integration due to their lack of legal status. Based on over five years of ethnographic fieldwork with mainly 1.5 and second generation Mexican-American men during a period of major healthcare reform, this paper addresses how citizenship status and embeddedness within multi-status communities impacts immigrant experiences in the healthcare domain. In particular, I argue that the Affordable Care Act (ACA) has contributed to an institutionalization of the status differences and a further differentiation in the social integration of these groups of children of immigrants. The novel methodological approach and the data which emerges through fieldwork reveals important insights into the process whereby healthcare reforms have consequences for immigrant communities which I show through highlighting the status-signaling event that is generated through various forms of direct and indirect interaction with the ACA. The implications of this extend beyond healthcare, and I discuss its impact on issues including ethnic identity and psychological well-being. This paper makes contributions to both our understanding of intergroup dynamics in immigrant integration and the health implications of immigration policies more generally.
Tuohy, Brian and Talen, Emily. “Urban Design in a New Age of Immigration” in City and Community, 16:4 (2017), pp. 374-379.
While much recent political debate on immigration has centered on the border, urban planners and sociologists have long known the distinct impact and challenges migration has on shaping the core and destiny of our cities. This work of urban planners and designers has played a key role in helping us understand the specific needs of immigrants and how best to capitalize on the benefits of a diverse and multicultural city. However, a lack of comprehensive federal immigration reform and the increasing significance of legal status in immigrant lives and communities have worked to challenge many of our assumptions related to immigration and the city. Undocumented immigrants, the majority of which reside in cities, face unique barriers to integration associated with their precarious legal status. Differences in state and more local governmental policies coupled with the distinct ways cities are planned and designed has led to variation in the life experiences of the undocumented. In this essay we will discuss these developments with regards to familiar theories and concepts in urban design and planning including access, connectivity, land use diversity and engagement. We will then discuss how each of these principles can be rethought to better account for undocumented residents. If city governments and local municipalities are to integrate these individuals into the dynamic socio-political and cultural environment of cities, it is necessary for urban planners to better account for their behavior, interests, concerns and life patterns. Bringing the tools of urban planning to bear on this issue will help us to think in new and creative ways about the role of urban design in the lives of this increasingly important population which presents both a challenge to planners and an opportunity for cities.
BOOK REVIEWS
Tuohy, Brian. “Building a Better Chicago: Race and Community Resistance to Urban Redevelopment” by Teresa Irene Gonzales. American Journal of Sociology (forthcoming)
Tuohy, Brian. “Fútbol in the Park: Immigrants, Soccer and the Creation of Social Ties” by David Rouille. Social Forces, 101:2, 2022, p.e5
MANUSCRIPTS UNDER REVIEW/IN PROGRESS
Tuohy, Brian. “ ‘It’s a place where we can feel comfortable:’ Citizenship Status and the Paradoxical Role of Safe Spaces in Immigrant Incorporation”
Previous literature rightly points to the exclusion undocumented immigrants and their family members experience in a variety of domains including education, employment and health. This has been heightened in recent years as anti-immigrant rhetoric directed at such vulnerable immigrants has intensified. With notable exceptions, less attention has been paid to the simultaneous experiences of belonging that occurs in daily life and the agency vulnerable populations have to carve out meaningful lives even in the face of these considerable constraints. This article, based on over five years of ethnographic fieldwork with immigrant men of varying legal statuses at a large soccer facility I call Chicharito’s Place in a predominantly Mexican American neighborhood in Chicago, builds upon this literature through highlighting the significance of “safe spaces”: spaces where individuals can feel comfortable regardless of citizenship status. I demonstrate the paradoxical role such spaces can play in both generating community while sharpening within group differences. More specifically I put forward “status signaling events” as a mechanism that contributes to deepening cleavages within socially similar immigrant groups that is a distinguishing characteristic of contemporary immigration often lost in conventional data sources that cannot identify it. These findings have implications for theories of immigration, stratification, and social reproduction of inequality.
Tuohy, Brian. “Productive Complicity in Ethnography: Exploring the Tension between Knowledge Production and Activism.”
Throughout the history of sociology there has been an assumption that producing “value-free” objective research limits community engaged activist-inspired sociological work that aims to improve and ameliorate social inequities. While sociologists have focused on ethical issues involved in conducting research with vulnerable populations, limited attention has been placed more specifically on the relationship between activism, ethnographic work, and research on health and illness. In this article I investigate the construct of “complicity” through questioning whether ethnographers can accomplish both research and activism through their scholarly work. I begin with a description of my ethnographic research on health experiences amongst a group of young men of varying legal statuses and then move to a substantive discussion that examines the ethical, moral and theoretical implications associated with the researcher role both with respect to knowledge production and the tension that emerges in efforts to ameliorate inequity. Questions will include: How should an ethnographer respond to instances of inequity they see in the field? What can and should researchers do? Does such work impact the collection of data? How does positionality and researcher understandings impact the project in productive and problematic ways? When research illuminates the structural inequities that produce disparities, what is the ethical responsibility of the researcher to those being researched?
BOOK PROJECT
Mexican Chicago: Between Belonging and Exclusion
In the context of a lack of comprehensive federal immigration reform since 1986, living “without papers” has led to the emergence of distinct status groups that I investigate in a particular fieldsite I call Chicharito’s Place and a social milieu I call Mexican Chicago. This fieldsite is an example of a “space of belonging” and part of a milieu that people incorporate into and that allows the undocumented a certain degree of comfort within which to interact and exist. Based on my dissertation research which included over five years of ethnographic fieldwork, this project employs an institutional based approach to immigrant incorporation that seeks to contribute to the emerging literature on the increasing significance of citizenship status in immigrant lives. I do this through fieldwork that investigates the concept of everyday belongings (the “work of daily life that sustains families and communities”) within a mixed status network. I argue for a distinct way of looking at the integration of Mexican Americans by highlighting the following: the power of undocumented status to alter incorporation trajectories, the multidimensional nature of the process generally that sees people moving forward in certain domains but not others, and the role that living within mixed-status communities plays in immigrant integration. In particular, I examine the experiences of two sociologically similar groups of children of immigrants: the undocumented 1.5 generation and their citizen-born, second-generation peers. I study these issues by delving deeply into a world where people are made similar by a sport and dissimilar when stepping outside these confines. It is society, our laws, and even our healthcare system that has worked to sharpen the distinction between and within this population. This institutional-based approach reveals spaces of belonging that add texture to theories and our understanding of undocumented life in the United States today.