A medical provider uses a nebulizer during a mobile health clinic visit on Maryland’s Eastern Shore. Such mobile clinics are part of an informal health care economy that has become essential to rural immigrant communities who are often shut out of formal systems of care. (Emilia M. Guevara)
Mid-sentence during our interview, David, a local physician and community clinic director on Maryland’s Eastern Shore, paused, looked past me out the window of his office, and said quietly: “No matter what I do, I feel like I am just putting Band-Aids on things that need stitches.”
A medical provider uses a nebulizer during a mobile health clinic visit on Maryland’s Eastern Shore. Such mobile clinics are part of an informal health care economy that has become essential to rural immigrant communities who are often shut out of formal systems of care. (Emilia M. Guevara)
He had just told me about an undocumented farmworker with diabetes who couldn’t afford the $400 insulin pen that would allow him to manage his condition while working in 110-degree chicken houses. David had been getting pharmaceutical representatives to give him free samples, essentially running his own informal medication distribution system. When his supervisors told him to stop providing this “free care,” David’s response was simple: “Why? Nothing is stopping me from continuing to do this for him.”
This is the reality of rural health care: providers and patients must create makeshift solutions to navigate systems that weren’t designed for their circumstances. On Maryland’s Eastern Shore and across rural America, both health care workers and immigrants have developed what I call “Band-Aid care”—temporary, improvised responses to permanent, structural problems.
The art of health care improvisation
Band-Aid care emerged repeatedly during my decade-long fieldwork. Providers used this metaphor to describe the temporary measures they undertake help those who require sustained attention but are systematically excluded from formal health care systems like hospitals, skilled nursing facilities, and primary care physician practices.
But Band-Aid care is far more than quick fixes. It represents an entire informal health care economy that has become essential to rural communities—a complex web of bartering, rationing, hoarding, strategic noncompliance and pure goodwill that keeps people alive when formal systems fail.
Elizabeth, the nurse practitioner who operated the region’s only mobile health unit, embodies this approach. When she needs to keep the mobile clinic van for an extra day beyond the rental period, she uses her personal credit card and gets reimbursed later by the federally qualified health center where she works. “Otherwise, no one would get care,” she says matter-of-factly. Her mobile clinic operates from a burgundy Dodge minivan, setting up under blue pop-up tents in farm fields and processing plant parking lots.
In rural immigrant communities, effective health care often looks more like community organizing than traditional medicine
Laura, another nurse practitioner, described the “creativity” required when a migrant client arrived from Texas with only a referral for an ultrasound to follow up on a breast mass—no previous mammogram, no insurance and limited availability for the procedure. “I do not have the original mammogram. I do not have anything to follow up with, and I have got to figure out how to get her over to the hospital, which has very limited hours for mammography, without impacting her work environment. She also has no insurance. And so you get very creative.” Laura often goes out of her way to find providers and hospitals that can offer free or discounted rates for services.
Patients as partners in improvisation
Health care workers aren’t alone in this improvisation. Immigrants and rural residents have become experts at navigating inadequate systems through informal networks and with creative problem-solving.
Isabelle, who was undocumented and worked cleaning houses, developed relationships with the families she worked for—many of whom were doctors’ and lawyers’ wives. “One family paid for my insulin at Walmart for eight months. Another paid my schooling fees for two years,” she told me, as she was studying nursing at the time. Through personal and professional networks, she found people willing to drive her to appointments, help her find medications online and assist with immigration paperwork through an immigration consultant. “I have always had people, really good people around me. My neighbor drives me to appointments, and my son helps me find the medications online. I am lucky.”
Sara, a physician working with migrant populations, developed her own system for managing medication shortages. When pharmacies made duplicate prescriptions by mistake or patients couldn’t pick up medications due to cost or transportation issues, rather than throwing these medications away, Sara says she saved them for “a rainy day”—when she could redistribute them to clients who couldn’t afford prescriptions or couldn’t come into the clinic.
These aren’t isolated examples of individual kindness. They represent a systematic pattern of informal care transactions that have become integral to how health care actually works in under-resourced rural communities.
The structural forces behind Band-Aid care
Why has this improvised system become so necessary? The answer lies in the collision between rural health care’s structural challenges and the specific needs of immigrant communities.
Rural health systems have experienced decades of hospital closures, reduced Medicare reimbursements and health care consolidation that prioritizes profit over patient care. Even Federally Qualified Health Centers (FQHCs)—designed as safety nets for underserved communities—operate under severe resource constraints. Federal Medicaid spending in rural areas is estimated to fall by $137 billion in the next decade as a result of the Republican reconciliation bill passed in July, according to a recent KFF report. This would “represent the biggest rollback in federal support for health coverage ever,” wrote Larry Levitt, KFF’s vice president for health policy. As rural health systems struggle through the next decade of spending cuts, Band-Aid care may become more necessary across the country.
Charity thrift store on Maryland’s Eastern Shore, part of the informal economy that many immigrant communities depend upon. (Emilia M. Guevara)
Randall, a provider whose mobile clinic was eliminated due to budget cuts, described trying to see 14 patients in less than an hour while processing blood samples in 90-degree heat: “They come with a bag where the label is faded, and it has got your name on it from last year, and they have four things that are really a problem.” The impossibility of providing adequate care under these conditions led him to focus on just a few immigrant labor camps, leaving others without services entirely.
For immigrant communities, these challenges are compounded by language barriers, transportation difficulties, insurance complications and fear of deportation. The result is a population with high health care needs but extremely limited access to formal care.
Beyond crisis response
What strikes me most about Band-Aid care is that it extends far beyond medical emergencies. Christine, a social services provider and nurse, says true care often means addressing what patients identify as their most urgent needs:
Anybody who is a provider knows that when somebody comes in, you can see their leg is practically ready to explode. But they are busy telling you their car broke down because that is the most important thing they need. So long ago, we learned to say, “What is the most important thing that’s happening at this minute? Let’s deal with that.” We honor what they think is a priority to stabilize their situation. We do what we call “stabilize the family,” interacting with landlords, utility companies, car mechanics, automobile insurance dealers, courts and public defenders.
Such a treatment process recognizes that health cannot be separated from housing stability, transportation access, legal status and economic security. This broader understanding of care also challenges conventional medical models that focus narrowly on clinical interventions. In rural immigrant communities, effective health care often looks more like community organizing than traditional medicine.
The ethics of improvisation
The prevalence of Band-Aid care raises important ethical questions. While these improvised solutions keep people alive and demonstrate remarkable human creativity and compassion, they also represent the failure of formal systems to adequately serve populations with significant needs.
Is it acceptable that health care depends on providers using personal credit cards, hoarding medications and working unpaid overtime? Should immigrants have to rely on informal bartering systems with their employers for basic medical care? These makeshift solutions, while admirable, shouldn’t be necessary in a wealthy nation with advanced health care infrastructure.
At the same time, Band-Aid care reveals something profound about human resilience and community building. These informal networks create relationships and mutual obligations that extend far beyond individual medical transactions.
David’s frustration about “putting Band-Aids on things that need stitches” reflects a deep truth about rural health care, and his willingness to continue providing insulin to his undocumented patients despite institutional pressure reveals something equally important. It represents a commitment to care that transcends bureaucratic boundaries, participating in what anthropologists call “moral economies”—systems of exchange based on reciprocity, care and shared responsibility rather than market logic.
Lessons for health care policy
Band-Aid care offers important insights for health care policy and rural development. Rather than viewing these informal systems as problems to be eliminated, we might ask what they reveal about what effective rural health care actually requires.
First, successful rural health care must be flexible and community-embedded rather than rigidly bureaucratic. The providers who are most effective are those who understand holistically their patients’ lives and can adapt their approach to local conditions.
Second, addressing rural health disparities requires confronting the structural inequalities that make Band-Aid care necessary in the first place: health care system consolidation, inadequate funding for safety-net providers, transportation barriers and immigration policies that make people afraid to seek care.
Finally, any sustainable solution must build on rather than displace the networks of care and mutual aid that rural communities have already created. The relationships, trust and local knowledge embedded in these informal systems represent valuable assets that formal health care systems should support rather than ignore.
Band-Aid care, with all its limitations, demonstrates that health care is fundamentally about relationships between people who care for each other despite structural obstacles. While we work toward systemic solutions to rural health disparities, these improvised networks of care remain lifelines for communities that formal systems have failed.
So, the next time you hear policymakers discuss rural health care, ask whether their solutions build on the creativity, relationships and local knowledge that already sustain these communities—or whether they risk dismantling the informal systems that, however imperfect, keep people alive when everything else fails.
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)
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