The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, healthy aging, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
October 6, 2020
Harold A. Pollack
Riyaa K. Randhawa
Jun 7, 2023
May 24, 2023
Nov 28, 2022
Back to The Milbank Quarterly Opinion
Thus far, the COVID-19 pandemic has taken more than 200,000 lives in the United States. In this frightening time, Americans understandably are focused on protecting themselves and safeguarding their borders, to prevent COVID-infected individuals from entering the country, and to marshal available resources for people at home.
That reaction, though understandable, is self-defeating and shortsighted. The United States, Mexico, and other Central and South American nations are a densely interconnected economic, agricultural, and epidemiologic system. Goods, agricultural products, animals, and people move back and forth across inherently porous borders. Infectious agents and other public health challenges follow these flows, as we have seen with COVID-19. In the absence of an effective vaccine, America cannot contain or control the COVID-19 pandemic without greater collaboration with its southern neighbors.
The need to collaborate is particularly strong as Central and South America are experiencing perhaps the worst COVID-19 challenge in the world. Among nations hardest-hit by COVID, the United States has, by far, the largest number of COVID-19 cases, but four of the next nine nations are in South or Central America. Ranked by COVID deaths per capita, seven of the world’s top nine nations are in Latin America. Another is the United States. Many residents of the hardest-hit nations live in crowded cities, often in multigeneration households. The public health response in these countries has been uneven. People lack access to personal protective equipment, and poor governance, poverty, and economic pressures hinder lockdowns, physical distancing, and contact tracing measures.
Aside from rising fatalities, COVID-19 has brought what the United Nations calls the region’s “worst health, economic, social and humanitarian crisis in a century,” inducing a 9% contraction in gross domestic product, and massive increases in joblessness, poverty, and social instability.
American policies make these problems worse, both at home and south of the border. Harsh, sometimes reckless immigration enforcement is particularly troublesome. American deportation of COVID-19-infected persons, now paused, posed the most immediate and direct risk to Mexico, Guatemala, and other nations.
Within the United States, COVID-19 is disproportionately prevalent among immigrants, authorized and unauthorized, whose countries of origin are south of the border. Many immigrants live in congested, multi-generation housing. Almost three-quarters of unauthorized immigrants work in essential occupations, often in crowded conditions that amplify COVID-19 risks. Lacking access to unemployment insurance, health insurance, or other social assistance programs, and unable to physically distance, many continue working out of economic necessity when they are sick, heightening transmission risk.
The COVID-19 pandemic coincides with intensified immigration enforcement, which magnifies community distrust of public authorities. Fear of deportation reinforces reluctance among unauthorized immigrants and those in mixed-immigration-status households to seek COVID-19 testing and care. This dynamic particularly undermines contact tracing, as many infected people are reluctant to name others.
Immigration jails and detention facilities pose further challenges. As of September 18, 2020, ICE reports 572 COVID-positive individuals currently in custody, and 5,878 cumulative cases. Under the best of circumstances, detention facilities mix unauthorized immigrants and foreign nationals in crowded conditions that pose inherent risk. Some departures from best practices have come to public attention, including one recent Virginia facility outbreak that infected more than 300 inmates, killing one. The outbreak apparently occurred after authorities flew detainees “to facilitate the rapid deployment of Homeland Security tactical teams to quell protests in Washington, circumventing restrictions on the use of charter flights for employee travel.”
Other immigration policies pose greater risks. As of June 29, more than 40,000 people had been expelled from the United States after crossing the US-Mexico border. An additional 30,000 asylum seekers were living in limbo, often in dangerous situations in northern Mexico. Turned away from the border, many migrants become domiciled in “overcrowded and unhygienic makeshift camps and shelters,” which lack proper protections against COVID spread. As one account notes: “Waiting with no clear end in sight with the threat of the virus all around is taking a toll.”
Harmful policies clearly should be curbed, but much more is needed. The hemisphere requires a coordinated response to economic, social, and public health vulnerabilities either worsened or revealed by the pandemic. Past responses to public health threats underscore the difficulties, but also the possibilities of such efforts.
Development experts estimate that Latin America will require up to $300 billion in financial assistance to address economic well-being and social determinants of health. Such assistance must focus on conditions of extreme inequality and the gaps in health infrastructure that allow the pandemic to take hold. These should include strategic investments in labor-intensive activities to promote and protect public health.
South America’s joint response to the 2009 H1N1 threat offers one valuable model. After the meeting of ministers from six South American countries, Brazilian Health Minister Temporao Jose Gomes noted the urgent need “to coordinate action; we need a comprehensive regional plan,” adding that “the region must share medicine and supplies to treat the sick.” South American nations shared resources and mounted an effective response.
Hurricane Katrina offers another model. When the United States struggled to maintain public safety and to assist thousands of displaced persons, Mexico sent 200 troops to assist with disaster relief, helping to save the lives of many Americans. Mexican personnel served 170,000 meals and helped to distribute more than 184,000 tons of supplies. Today, Mexico, Brazil, and other countries hard-hit by COVID possess impressive manufacturing capabilities that can be marshaled to ensure an adequate supply chain for PPE and other essentials across the hemisphere.
Collaborations such as the US-Mexico Border Infectious Disease Surveillance Project provide other useful models. Public health authorities in the United States and Mexico have collaborated to address challenges such as HIV prevention in neighboring states. Accomplishments include expanded syringe support programs, a nationwide mobile HIV prevention program serving marginalized populations, and more.
Outside the public eye, government and industry have long collaborated across borders in agricultural and veterinary public health through mundane-sounding forums, such as the North American Animal Health Committee, that address issues such as avian influenza and African swine flu. Between 1947 and 1954, the United States government financed a $120 million eradication effort (roughly $1.3 billion today) for foot and mouth cattle disease in seventeen Mexican states. The United States later assisted Argentina in similar efforts.
Right now, Americans are reluctant to share scarce, and sometimes costly, public health resources with southern neighbors. Looking ahead, though, such investments in common public health research and prevention are necessary and likely cost-effective. As Adetokunbo Lucas concludes, “International collaboration in health research [has] proved valuable for identifying risk factors, testing hypotheses generated in one locality at other sites, and developing and testing cost-effective technologies.”
On the prevention side, a single super-spreader event has been associated with 20,000 COVID cases in the Boston area. If one presumes a 3% case fatality risk, such an event is associated with approximately 600 deaths. Applying the EPA’s $9.5 million value-of-statistical life measure yields a valuation of $5.7 billion. The economic harm of nonfatal illnesses associated with such transmission adds another $900 million. Entirely from a U.S. perspective, a $10 billion initiative to reduce South- and Central-American transmission would be cost-effective if it prevented two such events.
Josiah Heyman, director of the Center for Inter-American and Border Studies at the University of Texas at El Paso, stresses that the United States and Mexico “can’t be kept separate… If there’s a problem on one side of the border, it flows to the other side.” The two nations must work together to address humanitarian catastrophes. There is no other way to defeat this pandemic.
Weinberg M, Waterman S, Lucas CA, et al. The U.S.-Mexico Border Infectious Disease Surveillance project: establishing bi-national border surveillance. Emerg Infect Dis. 2003;9(1):97-102. doi:10.3201/eid0901.020047
 Strathdee SA, Magis-Rodriguez C, Mays VM, Jimenez R, Patterson TL. The emerging HIV epidemic on the Mexico-U.S. border: an international case study characterizing the role of epidemiology in surveillance and response. Ann Epidemiol. 2012;22(6):426-438. doi:10.1016/j.annepidem.2012.04.002
 Ge Y, Sun S. Estimation of Coronavirus disease case-fatality risk in real time. Emerging Infectious Diseases. 2020;26(8):1922-1923. doi:10.3201/eid2608.201096.
Harold A. Pollack, PhD, is the Helen Ross Professor of Social Service Administration at the University of Chicago. He is faculty codirector of the University of Chicago Health Lab. He researches services for severely disadvantaged populations for individuals at the interface between Medicaid and the criminal justice system.
Riyaa K. Randhawa is a student researcher whose interests focus on technologies to improve conditions for disadvantaged and underserved populations.
Get the Latest from the Milbank Memorial Fund
An endowed operating foundation that engages in nonpartisan analysis, collaboration, and communication, with an emphasis on state health policy.