Borders of Care: Immigrants, Migrants, and the Fight for Health Care in the United States

Given the profound injustices of our current order—the dismantling of care resources, austerity politics, and the increased criminalization of immigrants, Beatrix Hoffman's Borders of Care is a timely history of the structures, policies, and individuals that have marginalized care for immigrants and of the immigrants who have organized for and improved health care in the United States. This book lays bare how interlocking systems of xenophobia, racism, sexism, and capitalism undergird the exploitation of immigrant and migrant workers and their woefully inadequate care. Hoffman describes chronologically—from 1848 to the present—health care in the United States through the themes of immigrant and migrant “exclusion, inclusion, and activism” and captures how care and justice are inseparable (p. 4).In describing the borders of care that immigrants have come up against, Hoffman begins her book by turning our attention to the histories of dispossession. After the United States acquired Mexican territories north of the Rio Grande in 1848, Mexicans in the region became citizens of the United States yet were treated as “foreigners in their own land” (p. 13). Hoffman explains that the growth of white populations in the Southwest and the stigmatization of Mexicans led to their segregation in barrios and colonias—these neighborhoods faced medical neglect and a dearth of public health services. For example, in 1919 Los Angeles established municipal health centers but in Mexican barrios like Belvedere, a separate Mexican clinic was established with scant resources in comparison to the clinics designated “for white Americans only” (p. 14).Weaving together historical evidence, Hoffman captures how and why the United States has excluded immigrants from care while also exploiting their labor—putting their health and lives at risk. Chinese immigrants who arrived in California during the 1848 Gold Rush, in one example, filled crucial jobs in agriculture, mining, and railroad construction yet lived in segregated communities and were denied health services. Hoffman illustrates how racial discrimination fueled a cycle where overcrowded segregated Chinese communities suffered from poor sanitation and a lack of medical care and were then condemned as “uncivilized” and a threat to public health. These stereotypes were often harnessed as a justification for excluding Chinese immigrants from care.Hoffman paints a rich picture of how immigrant labor exploitation and exclusion to health care continued throughout the twentieth century. In one example, the Bracero Program during World War II gave Mexican men temporary work permits in US agriculture where they were supposed to receive prevailing wages and medical care; however, the health of braceros often deteriorated because of overcrowded housing conditions, and workers in the fields often became sick from dehydration, pesticides, and overexertion. Yet, despite the contributions that braceros made to the United States—at great expense to their health and wellbeing—“employers and the government found ways to limit or deny their access to care, including pocketing workers’ insurance payments, denying that they were covered, and deporting them if they needed medical care” (p. 62).Deporting braceros who needed care is one example of an important contribution in Borders of Care: exclusion from care often rested on the intersection of US healthcare policies and immigration policies. For example, Hoffman describes how braceros filed complaints about their conditions but the “greatest obstacle to braceros’ claiming their rights was their deportability,” and congressional testimonies are “full of examples of braceros being returned to Mexico if they got sick” so that insurance companies would not have to pay insurance claims (p. 64). In another example, Hoffman describes how the Immigration Reform and Control Act (IRCA) provided amnesty for undocumented people, but less than a month after IRCA was enacted, Congress added AIDS to the list of conditions that made an immigrant excludable from the United States, illustrating how US immigration policy is harnessed to exclude based on a health condition.The intersection of healthcare and immigration policy is woven throughout Hoffman's book, underscoring the need to examine the devastating consequences of immigration policy on health. The stories that Hoffman provides on this intersection are many and include the University Hospital in San Diego refusing to accept a severely burned patient because of their immigration status; the United States attempting to deport a pregnant TPS holder from Honduras who was in a coma; border patrol violence and subsequent medical care delay; and border deaths in the desert as a result of attempted border crossings. These histories point to the harmful consequences of xenophobia, racism, border militarization, and the consequences of a society that does not provide universal healthcare for all who live within the United States.Borders of Care, however, is not solely about the exclusion of care. The book also powerfully attends to the struggles and activism for care among and on behalf of immigrants. One fascinating example was the United Farm Workers’ (UFW) opening of their own clinic—the Terronez clinic—which provided preventive and outpatient care. Hoffman shows how the clinic provided much more than health care for farmworkers: the clinic was also empowering and a “strategy for strengthening the union and recruiting new members” as the UFW portrayed its medical care as a benefit of membership in the union (p. 91). Hoffman wonderfully captures how the UFW viewed healthcare as not peripheral to their struggles but rather integral to their fight for justice (p. 92).Hoffman also illustrates how legal contestations and grassroots organizing for care often expanded rights for immigrants and for citizens alike. Hoffman shows through Guerrero v. Copper Queen Hospital—a legal case brought on behalf of two children who were denied emergency care—how legal contestation led to new rights. In 1972, when Saul and Lourdes Guerrero were badly burned from an explosion in Naco, Sonora, their parents rushed them to the nearest emergency room at Copper Queen Hospital in Bisbee, Arizona. A nurse at the hospital refused to let the children enter and advised the parents to take their children to the county hospital in Douglas, Arizona, which was twenty-five minutes away. The county hospital admitted the children and they survived, but Lourdes and Saul's parents contended that their children's suffering would have been less if they had been admitted to the first hospital. The parents sued Copper Queen Hospital for medical negligence and malpractice, and the Arizona Supreme Court ruled in their favor. As Hoffman shows, Guerrero v. Copper Queen created a new right to emergency care for everyone; indeed, the case was “one of a handful that created precedents for congressional action in the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA),” which required hospitals that have emergency departments to screen and stabilize anyone who sought their care (p. 141).Despite instances of inclusion to care, however, exclusions persist. As Hoffman illustratively argues, the xenophobic climate under Trump has hurt immigrant health. Hoffman provides heart-wrenching examples of the impact of Trump's policies: in 2017, border patrol agents entered the hospital room of a ten-year-old girl who was recovering from surgery and detained her; a newborn's parents were arrested in a hospital by immigration agents after seeking care for their sick baby; a breastfeeding baby was forcibly removed from their mother as a result of Trump's zero-tolerance policy.Hoffman ends her important book on the COVID-19 pandemic and the devastating impact it had on immigrant communities who had “more deaths among working-age people than did the general population” because of their disproportionate participation in essential work (p. 205). The COVID-19 pandemic exposed our interdependency, the value of care, and how survival is dependent on the care and well-being of other people. As Hoffman eloquently states, “the fight for immigrant health shows that borders are incompatible with health for all” (p. 211). This is the strength of Hoffman's Borders of Care—it captures the necessity of a politics of care that is inclusive of everyone, that recognizes our profound interdependency, and that is rooted in democratic practices. Borders of Care will be of great interest to scholars of immigration, scholars and practitioners of medicine, ethnic studies scholars, political theorists of care, and all who seek to live in and work towards a more caring and democratic society.