What Rural Healthcare Looks Like in ‘The Land that Time Forgot’

How immigrant workers navigate rural healthcare in Maryland’s Eastern Shore

Thurka Sangaramoorthy April 7, 2024

The following is an excerpt from Landscapes of Care: Immigration and Health in Rural America (University of North Carolina Press). Read our interview with the author here

I was nervous and excited to spend the day with Elizabeth, a nurse practitioner who runs the local mobile health unit. Her mobile team was the only one of its kind and offered care to those living in the furthest, most remote corners of the Eastern Shore of Maryland. Elizabeth and her team worked for a local federally qualified health center (FQHC), a community-based health care provider that receives funds from the U.S. government to provide primary care services in underserved areas. They operated the mobile health unit from June to August—the peak season for migrant workers in agriculture and seafood processing. I knew accompanying Elizabeth was a rare opportunity, and I felt grateful that she generously invited me on a trip to the local crab processing plants.

University of North Carolina Press

I agreed to meet the mobile health unit staff at the local Walmart parking lot outside Cambridge’s town center so that I could accompany them to their appointments that day. Cambridge sits on the Choptank River, a major tributary of the Chesapeake Bay on the Eastern Shore of Maryland about 90 miles southeast of Washington, D.C., the nation’s capital. Its waterfront, small town feel makes it a popular destination for nature lovers, recreation enthusiasts and history buffs alike. Initially inhabited by the Nanticoke people, English colonists violently colonized the area that would become Cambridge, Maryland, in 1684. Soon, Cambridge became a hub for the local slave trade. Harriet Tubman was born into slavery just a few miles away and escaped in 1849 with her two brothers. In the following years, Tubman returned to Cambridge to help free as many as 60 to 70 other enslaved people, including those who fled the auction block on the steps of the same Cambridge courthouse I was passing by. Years later, Cambridge became an unlikely epicenter of the nation’s civil rights movement, led by activist Gloria Richardson, head of the Cambridge Nonviolent Action Committee. Her iconic photo, where she fiercely pushed aside a National Guardsman’s bayonet with her sidelong glance at a local demonstration on July 21, 1963, sits in the Smithsonian’s National Museum of African American History and Culture. Today, Cambridge prides itself on charm, history and natural beauty. I shivered, thinking about how the courthouse was still in use today.

Elizabeth and her team arrived in a burgundy Dodge minivan a few minutes after I parked. At first, I felt confused. I expected a much bigger vehicle large enough to house a clinic office or exam room inside, but I had no time to process my surprise. Ellen, the medical assistant, poked her head out the window and yelled at me to get inside. I hopped on board the minivan in the blistering heat. The only seat available was between rattling medication cases, medical files, equipment and folding furniture. Nevertheless, I squeezed in. We drove through stretches of farmland, tidal marshland and mixed hardwood and loblolly pine forests, crossing over a series of bridges with panoramic views of the Chesapeake Bay, passing landmarks like St. Mary Star of the Sea and the iconic General Store. Some people from the area describe the Eastern Shore as “the land that time forgot.” It was easy to see why. The sudden isolation and stillness of the landscape were disquieting, as if we had physically crossed into a different place and time. My cell phone lost its signal entirely, and I did not see a single person, vehicle or home on our 40-minute drive.

Our first stop was a rustic restaurant on a grassy knoll. The restaurant was closed, but we were not there to dine. Instead, it was a pit stop where we got organized, notified the various seafood houses of our arrival and secured permission from owners to set up the mobile clinic on their property. I helped the staff spread out the medical files on the wooden benches outside that were typically reserved for outdoor dining. Then, I organized the prescription medications for migrant workers who Elizabeth had seen during previous visits. The medical files were disorganized; the workers’ names on the list provided by the seafood houses sometimes did not correspond to the names on the files. We did our best to match the medications to the appropriate patient files and then arranged them according to their employer. This filing system made it easier for the health team to distribute the prescriptions correctly to the women. I peeked at the medications that the team hoped to dispense on this trip. They varied, ranging from skin creams to pain relievers. Cuts, scrapes, rashes and skin infections were common among women working in crab processing. Some women also suffered from allergic reactions to vapor, salty water, bleach and other chemicals used in crab processing. In addition, women experienced minor injuries, chronic pain, tendinitis and myalgia from long hours picking crabs in crouched positions.

A mobile health unit in Maryland’s Eastern Shore. (Thurka Sangaramoorthy)

Matching medication to patient files took over two hours—much longer than anyone anticipated. It was past noon, and I was unsure how much time we had left to visit the crab houses. Elizabeth, however, was in a cheerful mood because she secured several health visits from crab processing plant managers. We filed back in the van and drove another few minutes to grab lunch at a modest convenience store with a small deli case, ice cream counter and a grill. In the backroom, we ate next to five older white men wearing trucker hats and smudged T-shirts. Elizabeth explained the plan for the rest of the day. I worried about how much of her schedule would get done, given that half the day had already passed. Finally, perhaps sensing my anxiety, she leaned over and told me that she needed to get the van back within 24 hours. Otherwise, she would pay for an extra day. Noticing my surprise, Elizabeth explained: “I use my personal credit card and then get reimbursed. Otherwise, no one would get care.”

I did not have time to inquire further into Elizabeth’s revelation because we were on the road again. Our first stop was what the staff referred to as the “telescope house,” so named because of its unusual accordion shape. As I stepped out of the van, the damp, pungent smell of crab chum and shells hit me like a ton of bricks. Working past my discomfort, I helped Sylvia and Camila, the two Spanish-language translators, unload all the equipment, files and medications from the van. We quickly unpacked the large tent and folding furniture, including two long tables and a few chairs. Next, Sylvia knocked on the front door to ask if anyone wanted to see the provider. Eight women filed out wearing shorts, T-shirts and flip-flops. I later learned that many of the women working in commercial crab processing on the Eastern Shore were from rural regions in eastern and north-central Mexico, such as Hidalgo and San Luis Potosí.

Migration has become a central strategy for rural development in these areas that have undergone substantial rural outmigration because of the devastation of small-scale agriculture brought about by the North American Free Trade Agreement and the Mexican neoconservative governmental regimes of 2000 to 2012. In turn, the intensification of induced labor migration has deepened gendered and racialized employment patterns globally, such as those found within commercial seafood processing. Economic conditions such as free trade, deregulation and privatization coupled with progressively harsh anti-immigrant policies have led to a global trend toward hyper-flexible labor strategies. Organizational practices such as nonstandard work arrangements and temporary, seasonal and informal immigrant workforce have become the norm among businesses struggling to succeed in increasingly competitive markets.

I introduced myself to Xiomara and Valeria, who were waiting in line to see Elizabeth. They represent foreign-born workers who account for a growing proportion (17.4%) of the U.S. civilian labor force, of which Hispanics/Latinos make up nearly half and Asians comprise 25%. In her late 30s and single, Xiomara picked crab for the same company for 13 years, from early spring to late fall. She had a father in Mexico and a brother and sister in the United States who were undocumented. Xiomara patiently explained that she left Mexico to work in crab processing because locally available jobs in orange and corn cultivation could not support basic survival needs: “You earn 400 to 500 pesos per week [US$20 to $25]. That is maybe enough to eat.” As the sole economic providers for their families, a trend throughout rural Mexico noted by other scholars, women like Xiomara face increased economic precarity, which led them to migrate for work. While official numbers show that foreign-born women’s share of labor participation is slightly less than their U.S.-born counterparts (53.4% versus 56.6%), they, like foreign-born men, are highly segregated in a handful of low-wage, service-oriented occupations and more likely to experience poverty than the native-born population.

Xiomara learned about crab processing jobs from family and friends. Her brother, who lives in Seattle, warned her that labor migration for women was particularly difficult because of the dangers posed by travel and work. He insisted that she contact a family friend for help: “So this young man helped me out. He checked it out, and he asked around, and that is why I came.” Using a recruiter to secure a temporary work visa intended for foreign workers, Xiomara took the three-day journey to Maryland’s Eastern Shore by bus from Monterey, Mexico. When she arrived, she was housed with 11 other Mexican female migrant workers in the telescope house. The women typically worked an average of eight to nine hours, sometimes more, depending on the daily crab supply. Xiomara showed us where they worked, directing us to the area where they had picked crabs a few hours earlier. It was a sizable sparse room that still felt wet and smelled of disinfectant. Inside, there were two long stainless steel tables. The walls and floors looked recently mopped and cleaned, and bilingual signs in Spanish and English instructing workers to wash their hands and wear boots hung prominently on the walls. Pointing to the stack of plastic containers and the sink area, Xiomara explained their work routine: “We pick up a plastic tub, and we rinse it with a water-bleach solution to disinfect it. We take out our tools, put on our apron, sit down, and fill the tubs. We separate the lump crabmeat from other meat and place it in a separate plastic cup. Every hour, the manager comes by and takes the crabmeat that you have produced and weighs it.”

Xiomara returns every year because crab processing work ensures survival despite the challenges of living and working in the United States: “We are here because of the work! Because in Mexico, you do not earn anything! Imagine, we are paid about 100 pesos [less than US$5] per day. And that is all day and all evening. If you make money here and then go back home, you end up living a different life. But you suffer when you are here. Slowly, you suffer without your family and home. But you return.” Valeria, who joined us after seeing Elizabeth, likewise affirmed: “It is because of work. That is why I came, too. If not for that, I would have stayed in Mexico. I am a single mother.” Valeria was in her mid-40s and a mother to four children ranging from 14 to 23-years-old. She explained that she was lonely and sad because she missed her family. This was her first year working as a crab picker, and she did not know any of the other women living with her. She confided that she was worried. Her supervisor gave her only a few days to adjust to the pace of work to meet the daily quota of 24 pounds of picked crabmeat. If she did not meet this quota by the deadline, her employer could send her back to Mexico.

From Landscapes of Care: Immigration and Health in Rural America by Thurka Sangaramoorthy. Copyright © 2023 by Thurka Sangaramoorthy. Used by permission of the University of North Carolina Press (www.uncpress.org).

Thurka Sangaramoorthy

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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