Beyond Legal Status: Rethinking Immigration and Health in Rural America

W[\dropcap]hen 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.

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 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.

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.

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 SangaramoorthyMore by this author →

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 (Routledge, 2020) and Treating AIDS: Politics of Difference, Paradox of Prevention (Rutgers University Press, 2014)