"Tonight we are going to talk about a tale of two Rochesters," said Mayo Clinic diversity program director Nicole Nfonoyim-Hara, invoking Dickens while kicking off a packed town hall on health care injustice here last week.
That theme, of hidden hardship in the shadow of southern Minnesota's comfortable standard of living and eye-popping health technologies, arose repeatedly at the event hosted by Mayo Clinic, the University of Minnesota Rochester, and the federally-supported care network known as Community Health Service Inc.
In an hour billed as "Hidden Crisis: Confronting Health Care Injustice in Our Local Immigrant Community," a succession of clinicians, academics and care providers painted a counter-portrait of ongoing health inequities, one in which the provision of health care has increasingly begun to call for not just practical but political action.
For the foreign-born refugees and immigrant communities that make up nearly half of all growth within Olmsted County, the event's speakers explained, health barriers that once came down to language, income and cultural differences have been recently compounded by a worsening political climate making ordinary participation in society perilous for wide swaths of the population.
"Rochester has always been welcoming," said Nasra Giama, a Somali health professional, clinical assistant professor of nursing at the University of Minnesota and Mayo Clinic researcher. "You can create the most beautiful clinic in the country, but if people don't have a way to get through those doors it can't help them."
Though they were launched in the early 1970s with an eye towards immigrant farm workers, so-called Federally Qualified Community Health Centers or FQHCs have become an increasingly critical point-of-contact for those on the margins. FQCHSs are located in locales as diverse as public schools, homeless shelters, public housing units, and serve one in five rural residents.
"The good thing about federally qualified health centers is we don't care where people are coming from," says Cristi Fernandez, community engagement coordinator at the Rochester CHSI, part of a seven-location network in rural and outstate Minnesota and North Dakota.
"We have people that drive from Wisconsin or Iowa to our local office. We have a mobile unit, and we've gone to Austin to see patients. We've been able to connect with dairy farms, and we reach out to the Amish community. When people can't come to us we go to them."
"The populations I work with who are undocumented or of mixed immigration status," said Dr. Seth Holmes of the University of California at Berkeley, "are generally given the opportunity for two kinds of work: food work on farms or in restaurants, and in construction," Both, he added, are professions with high rates of sickness.
"So there's this exchange going on in which the very people who provide our society with food and housing are the people whose health is being deteriorated by the fact that our society has a labor system segregated based on language and color of skin."
An invitee from the Kern Center for Innovation in Health Care Delivery at Mayo Clinic, Holmes called the arrangement "a relatively direct exchange in our society," adding that "I think we have a responsibility to learn about our neighbors..and to think about how we are voting."
"It's an election year," he said. "There's some amazing things being said about immigrants and about social difference. We need to speak differently about difference and immigration." Holmes then called on a speaker who drew out a need in strengthening our systems for health to take on the structures isolating undocumented workers.
"For the majority of my adult life I was undocumented until I was in high school," said Miriam Magaña Lopez a research and policy analyst from UC Berkely and board member of the Minnesota Immigrant Rights Action Committee. "My family relied on federally qualified clinics, and being an immigrant has been at the forefront of my experience."
Lopez then called for a sanctuary state platform, for persuading sheriff's departments not to cooperate with ICE, and for rewriting legislation to allow drivers licenses for undocumented persons.
"A lot of times the conversation around health is framed around the clinical encounter," Lopez said in a subsequent interview. "It's framed around getting your numbers checked, going to the doctor, or seeing a nurse. I think that conversation doesn't recognize how structural forces that don't allow people to fully participate in society negatively affect the health of communities."
"If your life is super stressful because you can't drive, because you can't leave your home without fear of deportation, all those things affect the body, and you have people getting sick."
"Allowing people the freedom to drive may not seem like it is directly improving health, but it is. You can go to the doctor, you can go to school, you can take your kids or yourself to the hospital and go to work without danger and you're not going to cause danger to other people."
"A person's documentation status doesn't determine how safe of a driver they are," she added. "Like it or not, these individuals are part of society, our society depends on them to function, and we owe it to everyone who is part of this community to help them be healthy."