[[link removed]]

BEYOND LEGAL STATUS: RETHINKING IMMIGRATION AND HEALTH IN RURAL
AMERICA  
[[link removed]]


 

Thurka Sangaramoorthy
July 7, 2025
Barn Raiser
[[link removed]]


*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

_ For immigrants on Maryland’s Eastern Shore, documentation does
not guarantee access to health care. Rural America is changing
rapidly, and immigrants are central to that transformation. _

Immigrant workers in uniform sort cut pieces of fish at seafood
packing plant in Jessup, Maryland., Photo: Edwin Remsberg, VWPics via
AP Images // Barn Raiser

 

When we talk about immigration in America, the conversation almost
inevitably centers on one question: Are they here legally or
illegally? This binary framework shapes everything from policy debates
to health care delivery, often reducing complex human experiences to a
simple legal category.

My ethnographic research over 10 years, from 2013-2023, on
Maryland’s Eastern Shore reveals how this legal/illegal binary is
not only inadequate but actively harmful to understanding the
realities of immigrant life in rural America, particularly when it
comes to health care access and community belonging.

In order to move beyond this reductive framework, we need new ways to
understand both the challenges immigrants face and the resilience they
demonstrate in navigating systems designed to exclude them.

THE LIMITS OF LEGAL CATEGORIES

During my fieldwork, I encountered Lud, a Haitian migrant worker who
had been traveling from Florida to Maryland for 13 years to pick and
pack tomatoes. When a local health organization arranged breast cancer
screenings for “migrant women,” Lud witnessed something that
crystallized the problems with how we categorize immigrants.

The health care workers proceeded to screen only Latina women,
refusing to allow Haitian women to participate. When questioned, they
stated that Haitians didn’t meet the inclusion criteria for the
screening—not because of their legal status, but because they
didn’t fit the workers’ conception of what a “migrant” looked
like. In their minds, being Black somehow disqualified these women
from the category of “migrant worker,” despite sharing identical
migration patterns, working conditions and labor trajectories with
their Latina counterparts. 

The legal/illegal framework inevitably creates hierarchies of
deservingness that obscure shared conditions and interests.

This incident reveals how racialization operates alongside and
sometimes independently of legal status to determine who receives care
and recognition. The Haitian women weren’t excluded because they
lacked proper documentation—they were excluded because anti-Black
racism rendered them invisible within the very category designed to
serve migrant workers.

WHEN DOCUMENTATION DOESN’T GUARANTEE ACCESS

The focus on legal status as the primary barrier to health care access
misses how other forms of exclusion operate. I met documented
immigrants who still faced significant barriers to care due to
language, cost, transportation and provider bias. Conversely, some
undocumented immigrants had developed sophisticated networks of
support that provided them with better care than some of their
documented counterparts.

Consider María, who arrived on a valid H-2B visa to work in crab
processing. Despite her legal status, she struggled to access
specialty care for a chronic condition because:

* The nearest specialist was 120 miles away
* Her employer-sponsored insurance had high deductibles she
couldn’t afford
* No providers in her area spoke Spanish
* Taking time off for medical appointments jeopardized her seasonal
employment

Meanwhile, Ana, who was undocumented, had developed a relationship
with a nurse practitioner who worked on a barter system. Ana received
comprehensive family care in exchange for the tamales she made,
creating a relationship that extended far beyond a simple service
transaction.

These examples illustrate how legal status alone doesn’t determine
access to care. Instead, a complex web of factors—including race,
language, geography, economic resources and social
connections—shapes immigrant experiences with health care systems.

The complexity of temporal status

Rural immigrants often exist in states of temporal uncertainty that
don’t fit neatly into legal/illegal categories. Temporary Protected
Status (TPS) recipients—such as immigrants from Haiti, Afghanistan
and Somalia, among others—live with the constant possibility that
their protection could be revoked. This fear has only been heightened
by the U.S. Supreme Court’s May 19 decision to uphold the Trump
administration’s attempt to end TPS for Venezuelans. (On July 1,
a federal judge blocked
[[link removed]] the
administration’s attempt to end TPS for Haitians). Seasonal workers
on H-2A and H-2B visas face annual uncertainty about whether they’ll
be selected in future years for the limited number of available
positions.

 
A mobile health unit in Maryland’s Eastern Shore.  (Photo: Thurka
Sangaramoorthy)
Robert and Esther, a Haitian couple with TPS status, found themselves
in a bureaucratic limbo when it came to health care. They were legally
authorized to work and live in the United States, but their temporary
status made them ineligible for many forms of public assistance. The
high cost of health insurance under the Affordable Care Act meant they
chose to remain uninsured and pay annual penalties rather than
purchase coverage they couldn’t afford.

“I will wait for another government,” Esther told me in 2015,
referring to her hope that future political changes might create
better options. “They have got to change that.”

This temporal precarity—the sense of living in an extended present
without clear futures—affects immigrants regardless of their current
legal status. It shapes how they make decisions about health care,
where they establish roots and how they understand their place in
American communities.

RACE AND THE POLITICS OF INCLUSION

Perhaps most significantly, the legal/illegal framework obscures how
race determines which immigrants are seen as deserving of care and
belonging. Throughout my fieldwork, I observed how anti-Black racism
marginalized Haitian immigrants, who shared similar legal statuses
with other immigrant groups.

Haitian workers often faced different treatment than their Latino
counterparts in poultry plants, with supervisors quick to dismiss
their concerns or fire them for minor infractions. When Haitian
communities sought health care services, they found fewer
interpreters, less culturally appropriate care and lower levels of
provider understanding about their specific needs and experiences.

This differential treatment wasn’t based on legal status—it was
based on how Blackness is perceived and devalued in American society,
including in rural areas like Maryland’s Eastern Shore where racial
hierarchies date back to the slave trade (Maryland was a slave state
until 1864, when it was abolished by the passage of the Maryland
Constitution).

Junior, a young Haitian man who worked in a poultry processing plant,
described how learning English became an act of resistance against
these racial hierarchies: “I think that the first time I said
‘no’ is the first time things started to get better. I remember
all of the guys in the line started treating me different because I
can talk to them now.” For him learning English became a tool for
asserting dignity and humanity within a system designed to render him
voiceless—a dynamic that extends far beyond questions of legal
documentation.

Yet just as racial hierarchies have deep historical roots in the area,
so too do movements of resistance. The Eastern Shore has long been a
site where marginalized communities have created networks of survival
and mutual aid despite—and because of—systemic exclusion. Harriet
Tubman, born into slavery just miles from where today’s immigrant
workers labor, conducted numerous missions through this region as part
of the Underground Railroad, helping enslaved people escape to
freedom. During the 1960s, Cambridge, Maryland, became an epicenter of
the civil rights movement under Gloria Richardson’s leadership, with
the Cambridge Nonviolent Action Committee challenging racial
segregation and economic inequality.

 
Gloria Richardson, head of the Cambridge Nonviolent Action Committee,
pushes a National Guardsman’s bayonet aside as she moves among a
crowd of Civil Rights activists protesting segregation in public
accommodations, on July 21, 1963, in Cambridge, Maryland. Maryland
Governor J. Millard Tawes had declared martial law on June 14. The
Cambridge movement refers to the series of protests in Dorchester
County, Maryland that lasted from late 1961 to the summer of 1964.
Today’s immigrant communities continue this legacy of resistance,
though their strategies necessarily differ. Like Tubman’s carefully
planned routes that relied on trusted networks and intimate knowledge
of local terrain, contemporary immigrants create what I call
“landscapes of care”—informal systems of mutual support that
operate outside official channels. When Junior learned to say “no”
in English, when Haitian workers organized to challenge exclusionary
health screenings, when Mexican women developed collective strategies
to access medical care during limited clinic hours, they were engaging
in acts of resistance that echo the Eastern Shore’s longer history
of people refusing the logic of their own disposability.

This historical continuity reveals how resistance emerges not just
from individual agency but from the collective knowledge that survival
requires building alternative systems when official ones fail to
recognize your full humanity.

STRUCTURAL VULNERABILITIES BEYOND STATUS

As the examples above illustrate, moving beyond the legal/illegal
framework allows us to see how structural vulnerabilities operate
across multiple dimensions. Rural immigrants face:

GEOGRAPHIC ISOLATION: Living in remote areas with limited
transportation options and significant distances to services.

ECONOMIC PRECARITY: Working in low-wage, often dangerous jobs with
minimal benefits and high injury rates.

SOCIAL MARGINALIZATION: Existing in communities where they may be
economically essential but socially unwelcome.

LINGUISTIC BARRIERS: Navigating systems designed primarily for English
speakers.

RACIAL DISCRIMINATION: Facing different treatment based on how their
bodies and identities are racialized.

TEMPORAL UNCERTAINTY: Living with the constant possibility of
economic, legal or personal disruption.

These vulnerabilities intersect in ways that don’t depend solely on
documentation status. An undocumented Mexican woman, a Haitian man
with TPS and a H-2B visa holder might face entirely different
challenges despite sharing rural geographic spaces.

BEYOND DESERVING AND UNDESERVING

The legal/illegal framework inevitably creates hierarchies of
deservingness that obscure shared conditions and interests. It
suggests that people with proper documentation deserve care and
support while those without it do not. This logic not only ignores how
legal status can change rapidly due to policy shifts or bureaucratic
errors, it also implies that human worth is determined by state
recognition.

Rural health care providers I interviewed often struggled with these
imposed categories. David, a physician who treats many immigrant
patients, expressed his frustration: “If you are poor, there are
patient assistance programs through the pharmaceutical company, but if
you’re undocumented, you are nothing.”

The reduction of human beings to “nothing” based on legal status
represents a profound ethical failure. It also ignores that fact that
these same individuals contribute labor, taxes, community
participation and cultural richness to rural areas that depend on
their presence.

ALTERNATIVE FRAMEWORKS

What emerges when we move beyond legal status is a more nuanced
understanding of how immigrants navigate rural America. Rather than
passive victims of policy or grateful recipients of services, we see
people making strategic decisions within constrained circumstances,
creating networks of mutual support and developing sophisticated
knowledge about how to survive and sometimes thrive in challenging
environments.

This perspective highlights:

AGENCY WITHIN CONSTRAINT: How immigrants make strategic decisions
about work, health and community participation despite limited
options.

KNOWLEDGE PRODUCTION: How immigrant communities develop expertise
about navigating rural systems that formal institutions often lack.

MUTUAL AID: How immigrants create support networks that operate
independently of formal services.

CULTURAL CONTRIBUTIONS: How immigrants reshape rural communities
through their presence, labor and social participation.

RESISTANCE PRACTICES: How immigrants challenge exclusionary systems
through everyday acts of refusal and assertion.

IMPLICATIONS FOR RURAL HEALTH CARE

For health care providers and systems serving rural immigrant
communities, moving beyond legal status opens up new possibilities for
care delivery. Rather than asking “Are they here legally?”
providers might ask:

* What barriers to care does this person face?
* How can we design services that are accessible across different
forms of vulnerability?
* What strengths and knowledge does this community bring that could
inform our approach?
* How can we create care relationships that recognize people’s
full humanity?

This shift requires developing what I call “structural
competence”—the ability to recognize and address the structural
conditions that shape health outcomes, rather than focusing solely on
individual behaviors or legal categories.

TOWARD MORE COMPLEX NARRATIVES

Rural America is changing rapidly, and immigrants are central to that
transformation. Rather than viewing this change through the narrow
lens of legal/illegal status, we need frameworks that capture the
complexity of how people create lives and communities under
challenging circumstances.

The stories I’ve shared from Maryland’s Eastern Shore reveal
immigrants as complex actors navigating multiple systems of inclusion
and exclusion. They demonstrate remarkable resilience while also
facing real vulnerabilities. They contribute essential labor while
experiencing social marginalization. They create innovation within
constraint while also needing support and resources.

As rural communities continue to grapple with demographic change,
economic transformation, and health care challenges, we need
analytical tools that match the complexity of lived experience. Only
by seeing immigrants in their full humanity—beyond simple legal
categories—can we develop responses that serve both immigrant
communities and rural America as a whole.

_[THURKA SANGARAMOORTHY is professor of anthropology at American
University. She is a cultural anthropologist with expertise in medical
anthropology and epidemiology. Her research focuses on improving care
for those living with HIV, developing more effective care systems for
non-citizen immigrants, amplifying local community expertise as a
transformative tool for enacting policies and practices that
effectively address disparate environmental risks in communities of
color, and advocating for social justice. Her writings on these topics
appear in a wide range of scholarly and mainstream publications. She
is also the author of Rapid Ethnographic Assessments: A Practical
Approach and Toolkit for Collaborative Community Research
[[link removed]] (Routledge,
2020) and Treating AIDS: Politics of Difference, Paradox of
Prevention
[[link removed]] (Rutgers
University Press, 2014)]_

_This article draws from the author’s research for her
book __Landscapes of Care: Immigration and Health in Rural America
[[link removed]], which examines
health care in rural immigrant communities on Maryland’s Eastern
Shore. (Read Barn Raiser’s interview with the author here
[[link removed]] and
an excerpt of the book here
[[link removed]])._

_Over the next six months, Barn Raiser will publish a six-part
series on rural immigrant experiences. Upcoming articles will explore
the women who work in Maryland’s crab industry, how rural providers
make do with “Band-Aid care,” racialized exclusion in health care
access and how networks of resistance and mutual aid sustain immigrant
communities._

_This story was originally published by Barn Raiser,
[[link removed]] your independent source for rural and
small town news. _

_Your independent source for rural and small town news._

_Barn Raiser [[link removed]] connects local and
national perspectives through a network of writers and contributors
who live in and care about rural and small town communities. By giving
voice to shared concerns, and by reporting on local organizing
strategies, Barn Raiser [[link removed]] will leaven
the commons with local connections._

* Rural America
[[link removed]]
* Maryland
[[link removed]]
* Maryland’s Eastern Shore
[[link removed]]
* Haitian refugees
[[link removed]]
* Haitian immigrants
[[link removed]]
* Farmworkers
[[link removed]]
* Farm Workers
[[link removed]]
* Migrant Workers
[[link removed]]
* immigrant workers
[[link removed]]
* immigrant women
[[link removed]]
* health care access
[[link removed]]
* immigrant communities
[[link removed]]

*
[[link removed]]
*
[[link removed]]
*
*
[[link removed]]

 

 

 

INTERPRET THE WORLD AND CHANGE IT

 

 

Submit via web
[[link removed]]

Submit via email
Frequently asked questions
[[link removed]]
Manage subscription
[[link removed]]
Visit xxxxxx.org
[[link removed]]

Twitter [[link removed]]

Facebook [[link removed]]

 




[link removed]

To unsubscribe, click the following link:
[link removed]