We live in a country that is in pain. Approximately 20% of Americans suffer from chronic pain. Through lost work and often ineffective treatment, chronic pain costs us $600 billion annually, more than cancer and heart disease combined. The emotional and social toll is uncountable. 
 
Pain is lodged at the crossroads of the two epidemics that have distinguished this decade: opioid addiction and suicide. Pain and its mitigation were the rationale for the profligate (and deceptive) marketing of opioids when prescription pill sales quadrupled between 1999 and 2014. That widespread misuse and addiction followed was, perhaps, not surprising. Physical pain is sometimes at the root of psychic pain; sometimes isolation and despair produce another form of suffering, leading to suicide. Our two epidemics meet at a crisis of pain.

For 40 years, HIV has been our most politically charged illness and the defining health challenge of our time. Our recollection of these decades contains visceral images of Kaposi’s sarcoma, a quilt that covered the National Mall, bodies of Giacometti emaciation, of Silence=Death written under overpasses, of fake blood thrown on politicians. HIV has been a disease of private hiding and public protest. It has been the disease of demands: for civil rights, for medical rights, for open and shared science, for enhanced and coordinated funding. HIV and its trail of discontent has driven the study of health disparities and animated global health.
 
At the same time, the world of HIV care over the last two decades has seen a great, almost miraculous, revolution. Today, a 35 year old who was HIV-infected in 2018 and takes her daily medication adherently has the life expectancy of a 35 year old without HIV infection. Monthly injections of long-acting HIV drugs look to be as good as daily pills at suppressing the virus, creating easier treatment. Medication to prophylactically prevent infection is 95% effective. Recent reports of two persons “cured” of HIV have created hope and impatience.

Throughout his political career, the current President has defined himself in large part by his antipathy towards immigrants; from hisdisparaging remarksabout Mexican immigrants (and judges) at the start of his presidential campaign, to his administration’sban on immigrants from several majority-Muslim countries. Leaving aside the callousness of such statements and actions, they have drowned out a conversation that we should be having about the health of immigrants.

Immigration is neither a new issue, nor an exclusively local one. In 2017, there were more than250 million immigrants living worldwide, and about 2.4 million migrate across national borders each year. It is estimated that more than750 million people live within their country of birth but in a different region, having migrated within national borders. Economic, political, and social forces drive migration. Migrants who are forced to leave their country due to war or persecution become refugees; there were 65 million refugees worldwide at the end of 2017. 

Housing is a foundational determinant of health and has been recognized as such since the early days of public health. In the 19th century, outbreaks of infectious diseases sparked interest in housing reform to address poor sanitation, crowding, and inadequate ventilation. One hundred and fifty years later, a report from the WHO commission on the social determinants of health has returned to the concept of “safe housing” as key to the health of populations.
 
There are ample data connecting poor housing conditions to a broad range of infectious diseases, chronic diseases, injuries, childhood development and nutrition issues, and to mental health. For example, substandard housing conditions such as poor ventilation, pest infestation, and water leaks are directly associated with the development and exacerbation of respiratory diseases, such as asthma. There are about 24 million Americans with asthma, and it is the most common chronic disease in children worldwide. About 40 percent of diagnosed childhood asthma is attributed to exposures at home.