“Illegality,” health problems, and return migration: Cases from a migrant sending community in Puebla, Mexico

“Illegality,” health problems, and return migration

Cases from a migrant sending community in Puebla, Mexico

Alison Elizabeth Lee

Abstract: This article examines several cases of undocumented workers who returned to their hometown in Mexico because of unresolved health problems they suff ered in the US. Their “illegal” status complicated the prospect of a full recovery and, therefore, played an important role in their decision to return to Mexico. Access to medical services, the prefer-ence to remain invisible to the state, demanding and dangerous working conditions, lack of worker benefi ts, low pay and separation from family members were important factors contributing to their health problems. Interviews with migrants highlight the contradictions between full inte-gration into the exploitative economic system and exclusion from health care. Data was collected from 2003 to 2005 and from 2011 to 2012 using ethnographic methods and in-depth interviews in a rural town in Mexico and New York City, the principal destination of the migrants from the town.

Keywords: Abjectivity, access to medical services, deservingness, immi-grant health, migrant “illegality”, undocumented migration, US-Mexico migration

Introduction

This article examines several cases of undocumented workers who re-turned to their hometown in Mexico because of unresolved health prob-lems they suff ered in the US. These health problems aff ected their physical and/or mental well-being and prevented them from continuing their jobs. Their “illegal” status complicated the prospect of a full recovery in the US and, therefore, played an important role in their decision to return to Mexico. While lack of access to health care was an important aspect of “il-legality” that prevented healing in some cases, it was not the only factor.

Regions & Cohesion Volume 3, Issue 1, Spring 2013: 62–93doi: 10.3167/reco.2013.030104 ISSN 2152-906X (Print), ISSN 2152-9078 (Online)

Lee • “Illegality,” health problems, and return migration 63

The fear of making oneself visible to the state by accessing health care, the tendency among undocumented workers to be forced into physically and mentally strenuous and dangerous (especially for those on bicycles) work routines and the lack of employer benefi ts (health insurance, sick time/pay, vacation time/pay) that might have helped weather a period of unemployment in order to recover are other ways in which “illegality” manifested itself. In the cases examined here, “illegality” also conditioned the separation of male workers from their partners, children and extended family who remained in Mexico. The resultant lack of moral and logistical support available to ill undocumented migrants made recovery in the US an especially diffi cult task. Finally, these issues are compounded by the general lack of economic resources of migrants who work in low-paying service jobs.

All but one of the case studies examined in this article emerged from research designed to understand the impact of the global economic crisis on pa erns of migration in a rural community in Puebla, Mexico which incorporated into international migration fl ows in the 1980s. Individu-als from this town, Zapotitlán Salinas, migrated principally to New York City without authorization. In 2011, we interviewed migrants who had re-turned to Mexico during the fi rst years of the economic crisis (2007–2009) in order to capture individuals’ experiences of the crisis, their strategies for dealing with reduced income in the case of those who had lost jobs or had working hours reduced, and their motivations for returning to their hometown. Out of the twenty-nine migrants interviewed, we expected to fi nd many cases of unemployment and underemployment, and we did fi nd four cases (Lee, forthcoming). However, what was unexpected was the number of people (fi ve) who discussed health problems as the primary motivation for returning.1

Return migrants did not generally believe they would have greater access to health care or higher quality health care in Mexico. Rather, the prospect of reuniting with one’s family, being able to rely on family and friends for assistance during recovery, switching to a less strenuous work routine, forgoing the pressures to pay rent and other expenses in New York without an income, and eliminating the burden created by the stigma of “illegality” were the combination of factors which made return a par-ticularly a ractive prospect. In a few cases, these changes in lifestyle were suffi cient enough to alleviate the health problems. Due to the nature of his injury, the one individual that did seek health care during recovery in Mexico had to see a relatively expensive private specialist, which he paid for from his own savings.

There is a growing literature that investigates undocumented mi-grants’ experiences with illness or other health concerns and their a empts

64 Regions & Cohesion • Spring 2013

to access care in host countries, many of which have policies which restrict their access to publicly-funded health care (Castañeda, 2009; Rosenthal, 2007; Ruiz-Casares et al., 2010; Willen, 2011). In the US, undocumented migrants have restricted access to non-emergency health care that is pub-licly-funded (Chavez, 2012; Derose et al., 2007; Heyman et al., 2009). They may receive some primary-care services through non-profi t community health centers funded primarily by the federal government, although the care is o en inadequate and they must pay for the service (Gusmano, 2012; Holmes, 2012; Martínez et al., 2005). Another alternative, to seek out private doctors or to pay out of pocket for care, represents an overwhelm-ingly expensive option for undocumented migrants who generally occupy the lowest-paid sectors of the labor market.

Investigating how the health problems of undocumented migrants and their inability to access adequate care lead them to decide to return to Mexico is a li le-studied topic (Gutmann, 2007).2,3 By closely examin-ing several individual cases, this article a empts to contribute to our un-derstanding of how “illegality” and health problems intersect in peoples’ lives and what role it plays in deciding to return to Mexico. To that end, it provides one answer to Willen et al’s call to understand what happens when undocumented migrants cannot access proper care (Willen et al., 2011, p. 340). As I will a empt to show below, the “illegal” status of the migrants played an important role in deciding to return to Mexico when illness struck.

Description of Zapotitlán Salinas

Zapotitlán Salinas, Puebla, is a rural town (pop. 2,700) located about four hours from Mexico City. Before the 1960s, goat ranching, salt production, and limited temporal agriculture were the main economic activities. In the 1960s, a local onyx extraction and processing industry developed, in-tegrating Zapotitlán into a national and international chain of commod-ity production. In the mid-1980s, men began to migrate to New York City and work principally in restaurants in order to salir adelante—to get ahead—by increasing their purchasing power through remi ances to pay for improved housing, their children’s education, ceremonial expenses, health care and, in a few cases, the start-up capital for a business. A er the local onyx extraction and processing industry virtually collapsed in the early 1990s through an interplay of both local, national and international factors, men, and increasingly women, migrated to New York in larger numbers (Lee, 2008). Every year new cinder-block houses were built and furnished with electronics and modern furniture, designer clothing and


shoes became the new standards for dress, and more late-model vehicles circulated through town. The timing of Zapotitlán´s development as a mi-grant sending community a er the passage of the US Immigration Con-trol and Reform Act in 1986 forced the vast majority (more than 90%) of migrant Zapotitecos to enter the US clandestinely as “illegals” with very few opportunities to regularize their status.

Since 2007, migration trends appear to have reversed: more individu-als are returning and fewer are leaving. A weakened job market, increased border enforcement, and increased violence associated with clandestine crossings play a role in these trends (Lee, forthcoming).

“Illegality”

Although “illegal” migrants have been studied for decades, it is only re-cently that scholars have turned the category of “illegal migrants” into an object of study (Ngai, 2004). De Genova (2002) argues that “illegal-ity” needs to be subjected to rigorous theoretical reformulation in order to specify more precisely how “illegality” is produced and the material eff ects of the law on the daily lives of undocumented migrants (see also Heyman, 2001). Coutin (2000, 2005) describes the way “illegality” creates “spaces of nonexistence” where migrants are physically present but le-gally absent from the nation-state. The erasure of personhood manifests as the inability to obtain work authorization and restricted physical and social mobility, which reinforces immigrants’ forced invisibility, exclusion and sense of vulnerability to being deported. Willen (2007) argues that in addition to the analyses of migrant “illegality” as a juridical status and a socio-political condition, it is necessary to a end to a third dimension of the everyday experience of “illegality,” namely, the embodied experiences of being-in-the-world. She argues that “illegality” extends deeply into mi-grants’ interiorized beings by “profoundly shaping their subjective experi-ences of time, space, embodiment, sociality, and self (p. 10 ).” In discussing Mexican migrants’ health problems and decisions to return to Mexico, it will be necessary to a end to these three dimensions of “illegality.”

“Illegality” as juridical status and socio-political condition

Migrant “illegality” in the US was produced through the creation and enactment of immigration laws principally during the 20th century (De Genova, 2005; Ngai, 2004). These laws have rendered Mexican undocu-mented migrants particularly vulnerable because of the profound depen-dence of US capitalism on their labor. Since the Mexican American War


(1846–48), US capitalist enterprises have imported Mexican labor on a massive scale to fi ll the working ranks in agriculture, industry and services (Cornelius, 1989; Durand & Massey, 2009; Galarza, 1964; García y Griego, 1996; Gómez-Quiñones, 1994). Currently, Mexicans represent the larg-est foreign-born population in the US (11.1 million) with approximately 6.1 million undocumented individuals (Passel et al., 2012; Pa ern, 2012). Before 1965, there were no quota limits imposed on Mexicans. However, following the 1965 Hart-Cellar Act, national annual quotas for “legal” migration were imposed on all nations. For Mexico, these “legal” quotas were far below the actual numbers of US-bound migrants. Since 1965, the number of undocumented workers has remained far above the quota for “legal” migration and Mexico has sent many more migrants to the US than any other country. A critical history of US immigration law clearly shows that since the 1965 amendments, more and more Mexicans have been relegated to “illegal” status (De Genova, 2005; Massey et al., 2002). De Genova (2005, pp. 229–236) argues that the law produces “illegality” without the intent to exclude Mexican labor from the US. Rather, immi-gration law in practice has created a “revolving-door” whereby Mexican labor has been subject to deportations, but this is within the context of a large-scale importation of Mexican labor.

In order to access US labor markets, “illegal” migrants must enter the US without being detected by federal immigration authorities. Since the late 1990s, most of Zapotitlán’s migrants have crossed clandestinely through the Arizona-Sonoran desert to reach the US, a relatively low-cost but risky journey.4 In order to avoid detection by the border patrol, mi-grants must trek for days through the desert around areas with heavy surveillance, and run and take cover when drones fl y overhead or they are pursued by Border Patrol vehicles. The massive border build-up to increase enforcement eff orts has come with a very high social cost. Thou-sands of migrants have died of exposure to the freezing cold nights in winter or the high temperatures in summer during their journeys (Corne-lius, 2001; Rubio-Goldsmith et al., 2006). In addition to these extreme con-ditions, migrants may be robbed or raped by criminal groups operating in the border area or be robbed, raped and abandoned by their coyotes. There is also increasing evidence that drug smuggling and people smug-gling operations are intertwined in the region where Zapotitecos cross, increasing the risk of physical harm (Lee, forthcoming; Slack & Whiteford, 2011).

In the US and elsewhere, scholars have increasingly focused on the way in which undocumented migrants’ “legal vulnerability” reaches into the myriad quotidian struggles they face in their neighborhoods, work-places, and the public spaces they frequent (Coutin, 2000; Gonzales &


Chavez, 2012; Menjívar, 2006; Sigona, 2012; Talavera et al., 2010; Willen, 2007). Since 2005, interior immigration enforcement in the US has in-creased both through federal programs and in the burgeoning numbers of so-called “local” (state and municipal) immigration control policies. One example of a federal program is E-Verify which allows employers to verify an applicant’s eligibility to work in the US, and, in practice, its threatened use is “wielded by employers looking to regulate or discipline an immi-grant labor force” (Gomberg-Munoz & Nussbaum-Barberena, 2011, p. 372). States have passed laws that restrict undocumented migrants from obtaining drivers’ licenses and accessing publicly funded services, such as education and health care, and cities have passed ordinances that penal-ize employers for hiring undocumented workers, penalize landlords for renting to undocumented people and authorize law enforcement offi cers to enforce civil immigration laws (Varsanyi, 2010). These anti-immigrant measures serve to increase undocumented migrants’ sense of vulnerability as well as their actual vulnerability to deportation in the interior (Passel et al., 2012).5 Deportability, De Genova (2005, p. 215) argues, is an essen-tial component of “illegality” and “provides an apparatus for sustaining Mexican migrants’ vulnerability and tractability—as workers—whose labor power, because it is deportable, becomes an eminently disposable commodity.” (see also Genova & Peutz, 2010) Migrants are rendered “le-gally vulnerable,” deportable, and, therefore, easily exploitable.

“Illegality” and Being-in-the-World

For the undocumented, legal personhood is erased in the receiving nation-state yet the condition of “illegality” is palpably lived and experienced through the body (Coutin, 2005). Infl uencing migrants’ physical and emotional well-being is their abject condition, which is understood as a combination of occupying the lowest and most wretched socio-economic position and embodying the “Other” in the nation-state, a subject that is unwanted and, therefore, “discardable” and expellable from the nation-state (Gonzales & Chavez, 2012, p. 256). The concept of abjectivity (abject and subjectivity) draws a ention to how migrants subjectively understand the process of living their abject life (Gonzalez & Chavez, 2012).

Ethnographic studies among undocumented migrants reveal that stress, anxiety, depression and bodily deterioration ensue from the psy-chological weight of the threat of deportation, self-imposed isolation, so-cial exclusion and rigorous and dangerous working conditions in the host country (Holmes, 2007; McGuire & Georges, 2003). Willen (2007) describes how a er the implementation of an Israeli government campaign to de-port “illegal” migrants in 2002, the criminalization and stigmatization of


migrants led to their experience of chronic tension and anxiety even when in the confi nes of their homes, and dread and fear when forced to go out into public to work.

Extending Willen’s analysis further into the realm of abjectivity, Ro-berto Gonzales and Leo Chavez (2012) examine the lived experiences of 1.5-generation undocumented Latino immigrants in California, individu-als brought to the United States at a young age by their immigrant parents. “1.5ers” have been socialized into US culture, embracing dominant no-tions of social and economic mobility achievable principally through hard work and education. Upon reaching the transition between adolescence and adulthood, however, these individuals o en traumatically confronted with their “illegality”. Without offi cial US documents, 1.5ers face extreme economic, social and educational mobility. Stress, anxiety and depression were a salient feature of their everyday life. While some individuals lost all hope for the future, others joined political campaigns to extend educa-tional opportunities and a path to citizenship for 1.5ers. In any case, “there is the suff ering that goes along with the contradictions of being raised in a society that fi nds you discardable (p. 268).”

“Illegality” as a juridical status, a socio-political condition and as being-in-the world shapes the varied lived experiences of stigmatization, marginalization and exclusion of undocumented migrants. “Illegality” also interpenetrates their experiences with illness and health care in host countries.

“Illegality” and the US healthcare system

In the US, access to healthcare is determined by one’s access to govern-ment or private medical insurance. Paying for medical care out of pocket is generally not possible for undocumented workers (nor citizens or legal residents without insurance) because of its high cost (Chavez, 2009; Hey-man et al., 2009). Among the undocumented, the percentage of migrants who are uninsured is higher when compared to legal immigrants and citizens. In Orange County, California, half of undocumented migrants lacked insurance compared with only 26% of legal residents and natural-ized citizens and 17% of US-born citizens (Chavez, 2012), a distribution quite similar to that reported for North Carolina (Hoff man, 2006).6 In New York, 44% of foreign-born Mexicans lacked health insurance, the highest rate among all foreign-born (New York City Department of Health and Mental Hygiene, 2006).7 Undocumented Mexican migrants generally do not have access to private medical insurance because they work in job sec-tors (restaurant work, construction, personal services, manufacturing, and farm work) in which employers do not extend this benefi t to them. I have


never interviewed or heard of an undocumented migrant from Zapotitlán that had healthcare through their employer.

Before the 1980s, undocumented migrants could o en access medical care through county and municipal hospitals and clinics, although some-times they had to prove residency in order to be eligible for the services (Hoff man, 2006). In 1986, the Immigration Reform and Control Act prohib-ited extending non-emergency health care to undocumented immigrants.8 In that same year, the Emergency Medical Treatment and Active Labor Act required hospitals receiving federal funding to provide emergency medical care to all persons, including the undocumented, and prevented the “dumping” of patients who could not pay for their care (Gusmano, 2012; Smith, 2010).9 The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 further cut social services and medical services to immigrants (including legal immigrants) and made it illegal for states to provide aid to undocumented migrants unless they passed their own legislation enabling it (Chavez, 2003, 2012; Derose et al., 2007; Hoff man, 2006). The political justifi cation behind these acts was that migrants over-burdened the healthcare system contributing to higher costs and reduced services for citizens, although scholars have shown that fewer govern-ment funds are spent on undocumented Latinos when compared to other groups and that there is an under-utilization of the healthcare system by this population (Chavez, 2012; Goldman et al., 2006; Mohanty et al., 2005; Stimpson et al., 2010).

In the state of New York, undocumented persons who are pregnant or have an emergency medical condition certifi ed by a doctor can gain access to emergency Medicaid, government health insurance for the poor funded jointly by the federal and state governments and managed by the states (Galvez, 2011; New York State Department of Health, 2012a).10 What constitutes an “emergency” is o en at the center of contentious debates, especially because public funding for indigent care is scarce.11 While the federal program may not pay for certain services under the emergency Medicaid program, states may decide to fund these services on their own. Organ transplants, a procedure that Cirilo needed (see below), are spe-cifi cally mentioned as being prohibited in the federal and New York state Medicaid program (Bernstein, 2011, 2012a; New York State Department of Health, 2012b).12

Federal and state policies that limit migrants’ access to healthcare cre-ate a climate where some groups are seen as “deserving” of healthcare (citizens, legal residents), whereas others are seen as “un-deserving” (the undocumented) (Derose et al., 2007). To what degree “un-deservingness” is internalized by migrants, becomes part of their abjectivity and therefore informs their decisions to not access care remains to be studied. One study


found that a er the 1996 reforms that restricted the use of government-funded health care by undocumented migrants, it appears as though “un-deservingness” was interiorized by even eligible immigrants because of their high rates of withdrawal from a government funded healthcare pro-gram for the needy (Hagan et al., 2003).

Undocumented migrants may be fearful that while accessing services they may be detected by or reported to immigration offi cials, that they will be turned away because they are undocumented, or that they may be ineligible for legal residence in the future as a result of seeking care because they demonstrated that they were a burden to the state; in these cases, these fears may prevent them from seeking care (Berk & Schur, 2001; Heyman et al., 2009; McGuire & Georges, 2003). This may prevent calling the emergency system, which may activate a police response, even if a particular situation requires emergency services. Maintaining one’s in-visibility is desirable, although it may come at the cost of one’s well-being in some cases.

Those that do manage to access care despite their undocumented status may experience misunderstandings and hostile interactions with doctors and other healthcare providers. Bonnie Bade describes how un-documented patients’ communication with health providers is impeded when they do not speak Spanish, resulting in mistrust, fear and irreso-lution of health problems (Bade, 1999). Seth Holmes describes how the “clinical gaze” of the doctors who treat undocumented indigenous farm workers in Washington and California excludes the social context (low pay, unhealthful working and living conditions, social marginalization) that contributes to their suff ering. As a result, doctors’ recommendations do not address undocumented patients’ health problems eff ectively and, in some cases, leads to prolonged illness and pain (Holmes, 2007, 2012).

Another aspect of “illegality” for many migrants from Mexico is the fact that undocumented migrants o en leave spouses and children behind in Mexico because of the cost and danger of clandestine border crossings and the higher cost of maintaining one’s family in the US. Transnational migrant families may endure years of separation (Dreby, 2010; Stephen, 2007; Zavella, 2011). Tamar Wilson argues that the combination of height-ened border enforcement, laws denying medical care and other social as-sistance to immigrants and highly publicized threats of deportation in the 1990s was to re-create and reinforce the separation of the reproduction of the labor force and its productive activity and therefore acquire a low-cost labor force. Migrant workers who leave their spouses or dependents behind surrender their surplus labor without “encumbrances.” Again, Mexican labor is not to be excluded; however, it is to be as low-cost as pos-


sible by transferring the cost of reproducing the next generation of work-ers from the state to the migrants (Wilson, 2000, p. 192). As a result, when sickness is experienced, migrants, especially those separated from their spouses, may not have the emotional support and the daily care necessary for a full recovery. Alternatively, they may not be able to not work during their recovery because they have no sick benefi ts or paid vacations, and, therefore, cannot pay their living expenses while they cannot work.

As “hard working immigrants”, undocumented migrants from Za-potitlán are aware that they produce much value and are appreciated by their employers, yet, for some, laboring conditions directly cause men-tal or physical illness, such as in the cases of Diego and Juan. Pablo and Alfonso’s legal vulnerability and social marginality as undocumented workers underpin the events that follow a er they are hit by cars on their bikes while working and a er leaving work. Cirilo’s story illuminates the ultimate disposability of indigent undocumented persons.13

Methods

The data on which this article is based was collected in several diff erent periods of fi eldwork. From January 2003 to August 2004, I lived in Za-potitlán for 18 months with two diff erent families whose male household head had migrated to New York leaving behind his wife and children. I conducted participant observation, by a ending numerous commu-nity events and celebrations, visiting families, and giving English classes to local school children. In 2004 I conducted a survey of 150 randomly selected households (an approximate 20% sample) using the Mexican Migration Project Ethnosurvey. From 2004 to 2005, I lived in New York conducting interviews with migrants from Zapotitlán in their homes and worksites. From this period of fi eldwork I developed an understanding of the economic, historic, social and cultural context in which international migration emerged and became a widespread phenomenon in Zapotitlán as well as villagers’ assessment of these changes (Lee, 2004, 2008).

In 2011 and 2012, I returned to Zapotitlán to initiate additional fi eld-work to understand the eff ects of economic crisis in the town. Our re-search team conducted surveys with 170 households (an approximate 25% sample) in order to detect changes in migration trends due to the economic crisis (Lee, forthcoming). We then conducted 29 semi-structured interviews with migrants who had returned from the US in 2007, 2008 or 2009 to gather information about the eff ects of economic crisis on labor and migration histories, motivations for return, and economic, social and


cultural reinsertion back into the home community. Twenty-two of these individuals were selected from the responses to the household survey; the remaining seven were individuals we met while conducting partici-pant-observation in the community. The interviews were transcribed and analyzed using the qualitative analysis so ware NVIVO 9.2.

Health problems and return migration

All but one of the following individual examples was collected during the semi-structured interviews with migrants who had returned from the US between 2007 and 2009. The last example, the story of Cirilo, was a case I learned about in 2004 when doing fi eldwork in New York City among undocumented migrants from Zapotitlán. Health problems and how they were, or were not, resolved were not the focus of the interviews with re-turn migrants. We were interested in knowing if the economic crisis had aff ected their employment prospects, the ability to send remi ances to their families, their spending and consumption habits, and their deci-sion to come back to Mexico. However, the number of individuals who talked about health problems as being the main motivation for return was notable. The individual cases that follow highlight two principal points. First, migrants express the inability to continue working because of health problems. Second, the health problems cannot be resolved satisfactorily because of one’s “illegal” status. In these cases, the migrants decided to return to Mexico.

Pablo

Pablo, 36, worked in a Kosher market in New York, 12 hours a day, 6 days a week. His goal was to stay for 5 years and then return to Zapotitlán. One night a er his shi , Pablo was riding in the bike lane on his way home. He preferred riding his bike in order to save money on bus fare. When he cycled past the front tire of a car parked in the bike lane, the car pulled out, hi ing Pablo and throwing him onto the other side of the street.

The woman (driver) was scared and she gets out of the car and asks, “Are you OK?” Everything went completely dark, and she helped me to the side of the street and asked “Do you want me to call the police? The am-bulance? How are you?” I was dazed. What I did was put my head down and I tried to relax because I was very upset. So, I didn’t say anything to the girl. She got up and le . The bicycle was destroyed. So I started to think about a lot of things, that sometimes one sacrifi ces a lot. Like not being with one’s family…Thank God nothing happened, just


something with the leg, my leg was injured. But I started to think about if I had lost my life… my wife and children would have been alone. And all for what? Just to make a li le more money, sometimes one sacrifi ces happiness for money. I’m be er off there [in Zapotitlán], although we get by day by day, but I can be with my family. My friends told me I should sue [the driver] so that I would get some money. I told them “I don’t want anything. Thank God I am OK, I don’t want anything to do with the money.” I decided to come back [to Zapotitlán]. (24 June 2011, Zapotitlán Salinas)14

New York law requires that when a person is injured by a motor vehicle, the driver must provide the injured party with their drivers’ license and insurance information, as well as notify the police. It is possible that the driver did provide her information to Pablo because he mentions the pos-sibility of bringing a lawsuit against her, which presupposes he had her basic information. When she asked him whether she should call the police or an ambulance, he said that he did not answer because he was trying to “relax” which gives the impression that he is in shock and trying to get his bearings a er the accident. Calling the police and the ambulance a er such an accident is good practice because it demonstrates that the person who was at fault is acting in good faith and providing all the necessary assistance to the injured party. In addition, emergency medical personnel can identify injuries that may appear superfi cial but, without treatment, might grow into more serious ma ers.

A call to the emergency system would have likely activated both a police and an ambulance response given the nature of the accident. It ap-pears that Pablo’ undocumented status made him reluctant to have the driver call the emergency system because of the possibility that the police, upon asking Pablo for identifi cation, would become aware of his undocu-mented status. Since the 1996 Illegal Immigration Reform and Immigrant Responsibility Act, local and state police can be authorized by the federal immigration authorities to enforce federal immigration laws (Immigra-tion and Customs Enforcement, 2012; Varsanyi, 2010). Although no police department in New York has signed such an agreement as of this writing (October 2012), the increasing anti-immigrant public discourse bolstered by such local and state immigration enforcement programs likely contrib-utes to migrants’ sense of vulnerability even in a state such as New York, which tends to be more accepting of migrants. Perhaps Pablo specifi cally told the driver not to call the emergency system to protect himself against a possible deportation that, however remote the possibility, would cause future fi nancial hardship.

Although it cannot be established based on this conversation, it may be possible that Pablo, like other undocumented migrants, had internal-


ized the idea that he was “undeserving” of medical services in the United States or that he would have to pay for the cost of medical services even if the accident was not his fault because he was in the country “illegally.” Perhaps these were additional reasons that he sought to avoid an emer-gency response to the situation. The fact that he did not think that he was deserving of any economic compensation from the driver also speaks to this experience of abjectivity.

If the driver had called the emergency system, these actions would require the driver to take full legal and fi nancial responsibility for the acci-dent. It is not clear whether she was seeking to avoid taking this responsi-bility or whether she knew that Pablo was undocumented, and therefore, sought to protect his identity at his behest. What is clear is that Pablo’s “illegal” status created a situation which prevented him from being able to trust the emergency system, receive the appropriate medical care and legal a ention, and allows the driver to sidestep the law. In the end, the thought of what could have happened if he had lost his life in the accident motivated Pablo to return to Mexico to be with his family. Rolando Gar-cia, a migrant from Zapotitlán, died in 2000 when he was hit on his bike delivering pizzas. The tragic death sent a shock through the town; it had been the fi rst death of a Zapotiteco in El Norte. The possibility of death for Pablo was probably all too real. As is the case for most undocumented workers, Pablo’ employer did not extend benefi ts such as life insurance. In case of his death, Pablo did not even have the satisfaction of knowing that his family would receive fi nancial compensation.

Alfonso

Alfonso, 56, worked in a bagel shop on Manha an’s Lower West Side and was struck on his bike by a taxi while making a delivery. His leg was caught in his bike frame as he fell down, and there were large cuts on his leg. Once he tried to stand up, the leg wouldn’t support the weight of his body.

Alison: Did the taxi stop?Alfonso: I saw the taxi stop about 50 meters away, but a li le bit later it kept on going … I tried to stand up, but I couldn’t. I think he [the driver] must have seen me try to stand up and fi gured that nothing had hap-pened to me.Alison: Were there other people who saw what happened? Alfonso: Yes, they saw it, you could hear the crash, but the taxi drove off rapidly … I was just two blocks from work and a paisano passed by. I asked him to call the manager and right away the owner came and took me to the hospital (3 June 2011, Zapotitlán Salinas).


Alfonso had broken bones and major tissue damage in his leg. He was in the hospital for a month and when he was released he stayed in his New York apartment for four more months, leaving only to go to his physi-cal therapy and doctor’s appointments. At the end of the four months, Alfonso walked slowly without crutches, but he couldn’t work making deliveries. Even work inside the restaurant would have required long pe-riods of time on his feet, something he was still not able to withstand at the time of the interview in 2011.

Although his healthcare expenses were paid for and his employer paid him his salary during the recovery, Alfonso decided to return home in 2007. He spent another year in physical therapy back in Mexico, spend-ing approximately 200USD per month for the therapy, doctor visits and medicine from his own savings. Finally, he found work in a tortilla factory that his brother owned in Zapotitlán. While the job does require standing for short periods, Alfonso can also sit on a stool when he is packaging tor-tillas for sale, and thereby maintain a job to partially support his family.

In the case of Alfonso, the driver of the taxi clearly violated the law by leaving the scene of the accident. In addition, without knowing the driver’s identity or the owner of the car, Alfonso could not bring a law-suit against them. However, because the accident happened while he was making a delivery, he was eligible for workers’ compensation benefi ts de-spite his “illegal” status, which provided the money for his medical care and lost wages while he could not work.15

Despite the fact that Alfonso could walk a er four months, he wasn’t able to return to work because making deliveries or preparing food in the kitchen required physical stamina which he no longer had as a result of the accident. As an “illegal,” his occupational mobility was restricted to hard, manual labor and his social networks were not suffi ciently extensive enough to help him locate other types of work, if, in fact, they did exist for someone without authorization. Further, his limited mobility required him to rely on others for assistance which was not a very satisfactory ar-rangement given the fact that his friends and roommates were also busy with their own jobs.16 Alone in the apartment and isolated from his social networks, Alfonso chose to return to his family in Zapotitlán where he would be surrounded by people with time for visiting and assisting in the activities associated with his recovery, the expenses of which he paid for from his savings.

Juan

Juan, 45, made six trips to New York, each lasting about 2 years. He always went to the US with a goal in mind: to build a house, buy a truck, build and


run a hotel. His “addiction” he says was to buy a phone card and talk with his wife and kids, “sometimes scolding them, sometimes congratulating them” but always to maintain good communication despite the long-term separations. As a consequence of having a specifi c goal, orienting his life toward Mexico and wanting to be involved with his family, he worked 13 hours per day, 7 days a week in order to shorten the overall time that he had to spend in the US. Each time he went to the US, he worked in a mar-ket, where he was in charge of the fi sh department. He did the ordering and set the prices, noting that the Korean owner trusted him to make all of these decisions in his department. He explained that his employer really appreciated him because Juan did “the work of two people.” His boss told him that when he le for Mexico, everything “gets out of control” because Juan had so many responsibilities and it was diffi cult to fi nd someone who could take his place.

Blanca Cordero (2007) provides an analysis of the “hard working im-migrant” discourse that is applicable to Zapotiteco migrants’ forms of expression about their experience in the US. Cordero discusses how un-documented Mexican migrants utilize a “working oneself to death” (tra-bajar para matarse) discourse as part of a shared understanding of what a migrant must do in the US to “be someone” (ser alguien) or to scale the social hierarchy (hacer algo) within the transnational migrant circuit. Traba-jar para matarse involves working 12 hours a day, six days a week, saving money to remit back and eliminating spending except on the most basic necessities in New York so that one’s economic situation may improve over the course of several years. Migrants mention that this routine is one of the most disagreeable aspects of being a migrant, yet it is inseparable from improving one’s social standing. Cordero argues that this discourse, as well as the new forms of consumption that are made possible to migrants through the participation in the US labor market, is part of the hegemonic disciplinary apparatus which creates an undocumented transnational working class out of poor, unskilled rural folk (pp. 187–226).

Being such a “good immigrant” by conforming to the hegemonic disci-plinary apparatus, takes a toll on the body. Working so many hours stand-ing, Juan developed a venous ulcer, and one of his veins ruptures causing excruciating pain.

Juan: I had a 13-hour a day job, and for that reason I think I am sick, I think, because my leg is injured, because I spend so much time standing, [I have] a venous ulcer. It bled and I have a wound. I’ve had this problem for 5 years.Alison: Did your boss help you?Juan: No. I asked for permission [to take time off of work] to go to the doctor. I went to 5 diff erent doctors and each one told me that I didn’t


have anything, that it was a fungus, that it was a wound. They gave me various [treatments].

Like most undocumented workers, Juan had no health insurance through his employer and paid for these unsuccessful doctors’ visits out of his own pocket. At the same time, the hours lost on the job were not compensated by his employer, a common situation for documented and undocumented workers. According to a survey administered to 500 restaurant workers in New York City, 91% did not have sick pay (Restaurant Opportunities Center New York 2009, p. 8). The frustration in his voice was evident when he recounted the incorrect diagnoses, a frustration which recalls the un-documented indigenous farmworkers in Washington studied by Holmes who claimed that the local clinic doctors “don’t know anything.” Holmes (2007) describes how the “clinical gaze” of the doctors who treat the farm workers excludes the social context (low pay, unhealthful working and living conditions, social marginalization) that contributes to their suff er-ing. As a result, doctors’ recommendations do not address indigenous’ patients’ health problems eff ectively, and in some cases lead to prolonged illness and pain.

Through family contacts, Juan found an immigrant doctor from India who clearly articulated the connection between Juan’s working conditions and the injured leg: he diagnosed the venous ulcer and told the migrant to wear a band around the leg to improve circulation and prevent the blood from pooling when Juan was at work. The wound healed.

Under New York state law, Juan would have been eligible for work-ers’ compensation for his work-related injury. However, Juan’s employer never informed him of his right to access workers compensation, a com-mon situation for immigrant employees in New York City. In the study of restaurant workers in New York City mentioned previously, researchers reported that very few immigrant workers knew about workers’ compen-sation and virtually never a empted to access it. Presumably in an at-tempt to keep their insurance rates from rising, employers fail to inform workers about their right to fi le workers’ compensation claims or instruct them not to report that an injury occurred on the job when they seek emer-gency care.17 Further, all the immigrant workers in the focus groups of this study reported that even when they did get injured, they would never be paid by their employer for days off from work (Restaurant Opportunities Center NY, 2009, pp. 14–15). As a result, workers continue to work even with injury or illness, as in Juan’s case.

Juan: But because I kept working at the same rhythm, [the treatment] wasn’t suffi cient. That’s why I came back [to Mexico], I arrived almost crippled. A er two months the wound healed, because here one lives a


diff erent life. For this reason I suff ered from [the venous ulcer]. I can’t work as much now because when I work right away my legs begins to hurt. (22 June 2011, Zapotitlán Salinas)

Juan’s “illegal” status conditioned the separation of his family across the US-Mexico border whereby the value realized by his productive activity is maximized by US capitalism while the cost of his family’s reproduction is assumed not by the US government, but by the migrant himself (Wilson, 2000). Juan could emotionally endure this separation if he knew that it would not last a long time; the several trips he has made to the US have all been approximately 2 years long. However, in order to earn the money necessary to pay off the smuggler’s fee, maintain himself in New York and his family in Zapotitlán, and save a portion of his salary to create small businesses back in Mexico to render future migration unnecessary, he “worked himself to death” (Cordero, 2007). For Juan, this process ended in a debilitating injury the costs of which he personally assumed despite his legal right to access benefi ts for work-related injuries.

Juan’s situation was not unique among those return migrants who were interviewed. Diego also worked 10 to 12 hours per day and 6, some-times 7, days a week to fulfi ll his dreams to save enough money and open a business back in Mexico. The business, he hoped, would make it un-necessary for him to have to migrate again and endure long separations from his wife and two children. Like Juan, Diego’s work routine eventu-ally led to health problems. The 38 year old was working 70–80 hour work weeks in a Spanish restaurant in Greenwich Village as both a cook and the kitchen manager. He returned to Zapotitlán in 2007.

Alison: Why did you decide to come back? Diego: Actually, it wasn’t a decision that I made, it was because of health problems. I had always stayed for three years and each time I came back, I came very stressed out because of work. In this case [on his last trip], a er 3 years I was again stressed out, but I took herbal remedies and they gave me more strength. The stress was under control, so I stayed for 5 years, but at 5 years I was at my limit, I was really stressed out, I couldn’t sleep and I had other health problems, all related to the stress. For that reason I had to come back, I couldn’t work anymore. But, actually, I liked my work. I was earning a lot of money. I just wanted to stay 1 more year. (8 June 2011, Zapotitlán Salinas)

At the worst point, Diego’s stress reached such levels that he was unable to sleep for an entire week. Back in Zapotitlán, it took him an entire year of not working to fully recover from the stress. The family lived off Diego’s savings and the money his wife made from selling tacos in the weekly market in town and from the small mom-and-pop store she owned.


Diego was proud of his ability to work hard at the same time that he was aware that his work represented a substantial savings in the cost of labor for his employer.

If I would have stayed, I would have done very well. I’m not saying this to be show-off . It is because I did the work of two people. I was chef and a line cook. I did the inventory, the orders and I also cooked. I was cheap labor for the owner because he didn’t have to hire a chef with a lot of experience. (8 June 2012, Zapotitlán Salinas).

When asked whether he thought that people who had recently returned to Zapotitlán had lost their jobs or if they had come for other reasons, he replied:

The people I know that have returned have not returned because there is no work, but because of health problems. The people I know in New York are still working in restaurants. (8 June 2012, Zapotitlán Salinas)

He mentions that his friends Santiago and Abel also returned to Zapotitlán recently because of the stress generated by their work schedule in restau-rants. These experiences are widespread among restaurant workers where the constant fast pace of physically demanding work creates a very stress-ful work environment. In the New York City restaurant worker study, 52% of workers surveyed experienced fatigue, 47% experienced headaches and 28% had trouble sleeping in the six months prior to the survey (Restaurant Opportunities Center NY, 2009, p. 17). For migrants such as Diego, these symptoms reached intolerable levels and played an important role in the decision to return to Zapotitlán.

Now Diego is owner of a successful restaurant in Zapotitlán. He ex-plained that he doesn’t really work fewer hours, but at least he sees his family all the time. His wife helps him in the kitchen and his children spend their a er school hours in the restaurant. “This is what was miss-ing there [in NY]. You get home late from work and there is no one to talk with.” (8 June 2012) Long work days are tolerable at home where one can enjoy the company of family.

Diego, like Juan, was interested in acquiring enough savings to open a business in Zapotitlán which would make unnecessary the need to be an “illegal alien” in the future, a dream which required him to take on enor-mous responsibilities at work without proper rest, in short, to “work him-self to death.” This arrangement was advantageous to his employer who reaped the rewards of a highly productive and skilled worker at a reduced rate. The work routine took a toll on Diego’s mental health that, despite his high productivity in the workplace, neither his employer nor the state was fi nancially responsible for. Without access to aff ordable healthcare, vaca-


tion or sick time from work which may have allowed him to recover and return to work, Diego returned to Mexico to rest and recover. He alone shouldered the high cost of his lost productivity. Diego and Juan do not view their work routines as exploitation as much as they express aware-ness of how their labor (and “cheap labor” as Diego said) contributes to their employers’ success. In any event, both migrants view “working one-self to death” as the appropriate way to gain respect and prestige in their community thereby conforming to the hegemonic disciplinary discourse (Cordero, 2007).

Cirilo

Fernanda and José lived in a 2-bedroom apartment in the Bronx section of New York City with their 3 children. José worked as a delivery person 6 days per week in lower Manha an and Fernanda provided child care for 2 young children during the week in the couple’s apartment. Their income was barely enough to cover the monthly rent ($700) and the family’s day-to-day expenses.

In 2002 and 2003, Fernanda and José suff ered personal tragedies. José’s younger brother, Edgar, 22 years old, died suddenly in New York City from a meningitis infection sending a shock through the community. Edgar’s wide network of family and friends in New York City collected $8,000 in 3 days in order to pay for the body’s transport back to Zapotitlán. Like virtually all Zapotitecos in New York, Edgar had no health insurance or life insurance off ered through his employer. Back in Mexico, his wife looked for employment to support their 2 small children and moved in with family members.

Several months before Edgar’s death, Fernanda’s brother, Cirilo, was diagnosed with Leukemia. He was told by doctors that his only hope was to have a bone marrow transplant, a treatment that would cost around $300,000. Although Cirilo had spent the previous three and a half years working in a small market 12 hours per day with only 2 or 3 days off per month, he earned only $400 per week and received no health insurance or other workers’ benefi ts. Paying for the treatment out-of-pocket was not possible because his “illegal” status relegated him to the ranks of the low-paid and he could not aff ord the price of the treatment. The transplant was also not considered an emergency; therefore, the procedure was not covered by the emergency Medicaid program.18

The doctors from the local hospital told Fernanda that Cirilo was not going to get be er and that he should go home to be with his family to die. The hospital did not want to assume the cost of caring for a terminally ill patient without insurance.


The doctor told me that my brother’s condition was very bad, “take him home so that he dies surrounded by the love of his family.” That’s what he told me! Can you believe it? What was I supposed to do? I mean, that doctor was so inhumane! And later, the hospital denied that the doctor had said that, but that is exactly what he said ….And then Cirilo told me that he wanted to go back to Mexico, that he didn’t want to die here. He said, ‘Thank you for all you have done, sister, but all that I want now is to go back to Mexico. I don’t want to be more of a burden here.’ (Fernanda, 2 October 2004, Bronx, NY)

There was no more money to send Cirilo home. Fernanda had given up watching additional children so that she could devote all her time to car-ing for her sick brother. A er Cirilo had been discharged from the hospital “to die at home,” Fernanda’s oldest daughter came down with pneumo-nia. In order to care for both Cirilo and the daughter, José decided to take a week off of work since Fernanda could not care for both at the same time. His boss granted him permission for a week off but told him to come back the following week. José agreed. Three days later, his boss called to tell him not to bother to come back; he had found another man to take José’s job. José’s absence represented a cost for the employer that he was unwilling to accept, despite his excellent work history. His responsibility for caring for his migrant family for a short period was not only unpaid but also cost him his job.

A college student learned of Cirilo’s wish to return home to die, so she contacted El Diario/La Prensa, a Spanish-language newspaper. The news-paper ran 4 stories which accompanied front-page headlines and pictures of Cirilo in May and June 2003 explaining his dire condition and his wish to die at home in Mexico “in his mother’s arms” (Acosta, 2003a, 2003b, 2003c, 2003d). Through the generosity of strangers, most of them Latino migrants themselves, Fernanda collected enough money for a plane ticket home for Cirilo, to pay for his pain medication and some of the other med-ical expenses that he had incurred. Cirilo died on 11 June 2003, 6 days a er returning to Zapotitlán.

It is possible that even if Cirilo had been able to access the most ad-vanced treatment available, he may not have survived. However, his “ille-gal” status had a negative eff ect on his prognosis. Like most undocumented migrants, Cirilo had no health insurance through his employer. Some of his medical expenses were covered through the emergency Medicaid program; however, the bone marrow transplant was not covered by the program.19

Caring for Cirilo at home represented an overwhelming burden for this undocumented family. In order to care for her terminally ill brother, Fernanda gave up her job. When her daughter became ill, her husband took time off work to care for the daughter. Despite making these arrange-


ments with his employer ahead of time, José was subsequently replaced by another migrant, clearly illustrating the disposability of the “illegal” migrant and causing further fi nancial hardship.

Finally, palliative care was not the responsibility of the state or em-ployer: Cirilo was “sent home to die” without hospice, and he had to pay the cost of pain medication. Ricardo Nuila (2012), a medical doctor, re-cently refl ected on end-of-life care for terminally-ill undocumented mi-grants through his personal experiences with patients in Texas. Although some undocumented cancer patients receive treatments paid for by county funds, others come to the hospital when their diseases are too advanced to treat with reasonable chances of survival. In these situations, care de-volves into trips to the emergency room where patients present “severe pain or organ failure” and doctors “stave off death well enough for them to be discharged, and very soon, they return … until the day they don’t” (p. 2047). Frustrated with this arrangement, Nuila advocates for the vol-untary repatriation of terminally ill patients back to their home countries: “…in a system in which emergency care for immigrants is being limited and adequate palliation for dying patients is not possible — a system in which dying people feel compelled to return to the hospital immediately a er discharge — sending the right patients home may be ethically neces-sary” (p. 2048). These repatriations would presumably be paid for by the patient’s home country (he provides the example of the Guatemalan con-sulate and Mexico’s Civil Protection agency, institutions that have assumed responsibility for repatriating terminally-ill migrants) and would lessen fi -nancial strains on county funds for indigent care or emergency Medicaid.

Indeed, those wishing to return home in their fi nal days to say good-bye to family members that they may not have seen in years and be as-sured of their fi nal resting place should have the comfort of knowing that the country that could not guarantee a dignifi ed life for its workers could at least provide a dignifi ed end-of-life experience. At the same time, in practice, there is surely a fi ne line between “granting a dying person’s last wish” and involuntary repatriation, or “patient dumping” (Smith, 2010), which ultimately shi s the burden of care not only onto the home country but also back onto the migrant family which seems absurd given that the vast majority of migrants from Mexico came to the US to work and sup-port their families back home because of fi nancial hardships and lack of economic opportunities in their home countries (Durand & Massey, 2009; Massey et al., 2002).

The “slippage” between voluntary repatriation of dying migrants and “patient dumping” seems entirely too possible given the “illegal” status of these individuals who, when scarce public funds prevent adequate care and anti-immigrant sentiment reaches unprecedented levels, are easily


cast into the “un-deserving” category. While their healthy bodies produce the surplus value that is siphoned off by employers and the government, their terminally-ill bodies are easily cast off to languish in an emergency-only style of care which permits unimaginable suff ering. Cast outside the moral community of the legally privileged classes, the palliative care of the dying body falls to the migrants’ families or communities. The cost of reproduction (and dying) of the workforce is forced out onto the workers as much as possible.

Conclusions

Zapotitecos, along with millions of other Mexicans, incorporated into international migration fl ows beginning in the 1980s expecting to salir adelante and improve their economic situation. Over ninety-percent of migrants from the town have migrated without documents, and without even the possibility of regularizing their status in the future. It is their “illegal” status in the destination that forces them to cross the US-Mexico border clandestinely, limits their economic and social mobility, shapes the quality of their daily lives and limits their options when they become sick or injured.

“Illegality” as a juridical status and a sociopolitical condition deter-mines Zapotitlán’s undocumented migrants’ particular insertion in the New York City labor market in low-paying service jobs with physically and emotionally taxing work routines (Restaurant Opportunities Center, 2009). These jobs do not provide workers with benefi ts such as private health care or sick pay that might be used to seek treatment and recover from injury or illness. Undocumented workers injured on the job may not utilize the workers’ compensation benefi ts entitled to them by law because they are not informed about this option by their employer, or their em-ployer may instruct them to report that the injury did not occur while working. In this way, employers avoid responsibility for work-related injury and may reduce their insurance costs. Finally, publicly-funded health care for undocumented workers through the Medicaid program is restricted to emergencies only, a requirement that may exclude situa-tions in which migrants require health care to protect their well-being. The limitations and restrictions for undocumented workers’ health care contributes to the production of a low cost labor force for a country which cannot reconcile its voracious need for undocumented migrant labor and the physical and cultural presence of the people who provide that labor.

Along with the erasure of legal personhood, “illegality” manifests in the migrant body as unlawfully infl icted injuries, stress, and physical


deterioration a ributable to demanding work routines. The “illegal” mi-grant infl icted with cancer cannot expect that the country that covets his labor will provide a healthcare system to treat the disease adequately. No one is responsible for the injured, sick and diseased “illegal” bodies except the migrants themselves, their families, their communities.

Nor does the future look much brighter. Healthcare reform in the United States does not include “illegal” migrants. The Patient Protection and Aff ordable Care Act of 2010, the largest reform to the US health care system since the 1960s, aims to reduce the number of persons in the United States without health insurance by approximately 36 million and reduce the costs of healthcare services in general. However, “illegal” immigrants are specifi cally exempt from the program. Furthermore, they are perhaps made further vulnerable by the passage of the healthcare law because fed-eral funds for the emergency Medicaid program are to be reduced over the next decade. The logic behind this reduction involves the belief that more individuals will be enrolled in healthcare plans through the law and therefore, less funding will be needed for emergency Medicaid. Hospi-tals’ will have even fewer resources to channel toward “illegal” migrants’ health problems (Bernstein, 2012b).

Young, undocumented migrants, the so-called “Dreamers,” were also dealt a blow with respect to healthcare in 2012. “Dreamers” is a term that is derived from the DREAM Act (Development, Relief and Education for Alien Minors), originally proposed in the US Congress in 2001, that would bestow conditional permanent residency for 6 years to undocumented mi-grants of good moral character, who graduate from US high schools, ar-rived in the US as minors, and lived in the country continuously for at least 5 years prior to the act’s enactment (approximately 1.7 million individuals). During the 6 year period, if they served in the military or completed at least 2 years in an undergraduate program, they would be eligible for per-manent residency. Although the DREAM Act has not been passed by Con-gress, President Barak Obama implemented a program in August 2012, the Deferred Action for Childhood Arrivals program, an initiative that would stop deportation proceedings against any person who met the criteria for the original DREAM Act proposal. However, these individuals are not con-sidered “lawfully present” in the nation; therefore, they are not eligible for any government-funded insurance program (Gusmano, 2012).

ACKNOWLEDGEMENTS

The 2003 to 2005 research was generously supported by the Fulbright-Hays Dis-sertation Research Abroad Program, a National Science Foundation Dissertation


Improvement Grant (Award ID Number 0314250), a University of California Insti-tute for Mexico and the United States (UCMEXUS) Dissertation Research Grant, the University of California Offi ce of the President’s Pacifi c Rim Research Program, and a University of California, Riverside Graduate Dean’s Dissertation Research Grant. The 2011 and 2012 research is part of the project Crisis Económica Global y Respuesta en Tres Comunidades de Reciente Migración funded by the Mexican Con-sejo Nacional de Ciencia y Tecnología (CONACYT: #CB-2008-01-00102222). I am very grateful for the support of these organizations. The opinions expressed in this article are mine and do not refl ect the opinions of these funding organizations. A portion of this paper was presented at the 2009 RISC annual conference as part of a panel organized by Harlan Koff entitled Border (Re)confi gurations and their Impacts on Human Security in Diff erent Migration Regimes. Harlan Koff , Lourdes Fernan-dez, and two anonymous reviewers graciously provided constructive comments on an earlier dra of this paper. I would like to kindly thank Mario Macias, Karla Buenrostro, María del Pilar Salazar, Gabriela Saavedra, Ana Lara, Ana Rosa De La Cruz, Ana Laguna and Andrea Avendaño for help with data collection and tran-scriptions of the interviews with informants from the 2011 fi eld season. I sincerely appreciate their hard work on this project. All errors are my responsibility.

ALISON LEE is an assistant professor in the Department of Anthropology at the Universidad de las Americas Puebla, Mexico. Her current research focuses on the economic, social and cultural impact of global economic crisis on undocumented migrants, their families and communities in rural and peri-urban communities in Puebla, Mexico.

NOTES

1. Of the fi ve who returned due to health problems, four cases are presented here. Cirilo’s case, discussed below, came from data from an earlier period of fi eldwork. The other reasons for return were deportation (2), injury running from border patrol in the Arizona-Sonora desert (1), obligations to care for a sick family member in Mexico (1) and family reunifi cation (16).

2. Gutmann (2007) analyzes how migration from the southern Mexican state of Oaxaca to the United States contributes signifi cantly to HIV infection among migrants. He argues that “…despite their illegal status, Mexicans might still have received more adequate treatment for their suff ering in some states, and thus many stayed in the [United States] as long as they could, o en only re-turning to Oaxaca and other parts of Mexico in the fi nal stages of the dis-ease to die in their natal land.” (p. 94) However, because of the wave of legal initiatives a er 2005 to limit migrants’ access to health care and other social services, migrants were less likely to be able to access care for their condition. (see also Varsanyi 2010)

3. Some scholars have studied how Mexicans living in the US near the US-Mex-ico border cross back into Mexico in order to access health care, alternative therapies, and medications for a variety of reasons (Chavez 1984; Heyman,


Núñez, & Talavera, 2009; Martínez, Runsten, & Ricárdez, 2005). This option is primarily available to those who live near the border and have authoriza-tion due to the diffi culties crossing the border back into the United States for those without authorization. This strategy is not available to undocumented migrants in New York, of course.

4. Crossing through the desert on a several day hike cost around 1800USD whereas crossing through a border checkpoint with false documents was ap-proximately 3500USD. These fi gures are from our semi-structured interviews with return migrants in 2011 and do not include the expense of travel to the border and maintaining oneself at the border during multiple a empts.

5. According to Passel et al. (2012, p. 24), “about one-in-six migrants sent back to Mexico (17%) were apprehended at work or at home in 2010. This share represents a notable increase from previous years—in 2005, only 3% were ap-prehended at home or at work.”

6. Hoff man (2006:244) states: “In 2003, 69 percent of Hispanics in North Carolina whose primary language was Spanish had no health insurance. In compari-son, 32 percent of English-speaking Hispanics, 19 percent of African Ameri-cans, and 13 percent of whites in North Carolina lacked health coverage.”

7. The fi gures from North Carolina and New York probably also include some legal residents or naturalized citizens. However, both areas have high levels of recent migrants who entered a er the passage of IRCA in 1986 most of whom are likely to be undocumented.

8. Hoff man (2006) mentions that even legal immigrants were barred from Med-icaid during their fi rst fi ve years in the country. (p. 242)

9. However, Smith (2010) provides evidence that patient dumping is still a prob-lem, including the forced repatriation of undocumented migrants with severe health problems back to their home countries usually at the expense of the US hospital and without the authorization (but with the tacit approval) of the US immigration authority.

10. Eligibility rules vary from state to state, however, the federal law considers an emergency to be a “med ical con di tion man i fest ing itself by acute symp toms of suffi cient sever ity such that the absence of imme di ate med ical a en tion could rea son ably be expected to result in – (i) [p]lacing the health of the indi-vid ual … in seri ous jeop ardy; (ii) [s]erious impair ment to bod ily func tions; or (iii) [s]erious dys func tion of any bod ily organ part[.]”. (Gusmano, 2012)

11. For example, in 2007, federal auditors told New York State health authorities that chemotherapy treatments to undocumented persons did not qualify for coverage within the Medicaid emergency plan (Kershaw, 2007).

12. Undocumented migrants may receive some primary-care services through non-profi t community health centers funded primarily by the federal govern-ment (Gusmano, 2012). These centers charge for services based on a sliding scale, which, while making health care more aff ordable, can still be an ex-pensive option for low-income migrants. Long wait times, language barri-ers, and lack of cultural sensitivity, even among well-meaning and dedicated clinicians, are other factors that create barriers to adequate care (Galvez, 2011; Holmes, 2012; Martínez et al., 2005). Within New York City, there are 12 clin-


ics which serve 75,000 individuals on an annual basis (h p://www.chnnyc.org/about/overview/). However, there are approximately half a million un-documented persons in the city (Fiscal Policy Institute, 2007). Despite the enormous contribution community clinics make, it is unlikely to meet all the health care needs of the undocumented population.

13. All informants’ names are pseudonyms with the exception of Cirilo whose name was published in El Diario/La Prensa, a Spanish-language newspaper in New York.

14. All interviews were conducted in Spanish and all translations are mine.15. Undocumented workers are not always successful in seeking worker’s com-

pensation benefi ts when they have been injured on the job. For example, Vic-tor Leon was paralyzed from the waist down when he fell off a three-story building doing construction work in West Palm Beach, Florida in 2006. In 2009, he had still not received any compensation from the company who em-ployed him; they denied his case because of his “illegal” status. At the time of the report, he was homeless and lived off whatever charitable contribu-tions concerned neighbors and local churches provided (Copsey & Deering, 2009).

16. Virtually all migrants from Zapotitlán are wage earners in the US. 17. A variant on this theme was illustrated by the case of a worker from Zapotit-

lán who was told by his employer that if he took him to the emergency room to treat the severe cut on his hand, it was likely that the hospital would report his illegal status to the authorities and he would be deported. The worker did what he could to stop the bleeding in the employee’s bathroom and went back to work without seeking medical care.

18. Newspaper reports indicated that the National Institute of Health in Washing-ton promised to evaluate Cirilo’s case early in 2003, but by then the migrant’s health was too poor for him to make the trip to the nation’s capital (Acosta, 2003a, 2003b, 2003c, 2003d).

19. Cirilo’s situation may not be uncommon. Ten year old Pedro Baltazar Loza, who suff ered from end-stage renal disease, was able to receive free dialysis through emergency Medicaid system to keep him alive because this consti-tuted a medical emergency. However, emergency Medicaid did not cover the kidney transplant (his mother could have provided the organ) and the Wash-ington State legislature cut funds for undocumented children’s health care in early 2003 that would normally pay for such a procedure (Foster 2003). Undocumented individuals who receive organ transplants do so because of generous private funding (Hoff man 2006; Bernstein 2012a).

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“Ilegalidad”, problemas de salud, y migración de retorno: los casos de una comunidad migrante de origen en Puebla, México


Resumen: Este artículo examina varios casos de trabajadores indocumen-tados quienes retornaron a su pueblo natal en México, debido a proble-mas de salud no resueltos que sufrieron en los Estados Unidos. Su estatus "ilegal" complicó las perspectivas de una completa recuperación y, por lo tanto, jugó un papel importante en su decisión de regresar a México. El acceso a los servicios médicos, la preferencia de permanecer invisibles para el Estado, las exigentes y peligrosas condiciones de trabajo, la falta de benefi cios laborales, los bajos salarios y la separación de los miembros de la familia, fueron factores importantes que contribuyeron a sus pro-blemas de salud. Las entrevistas con los migrantes destacan las contra-dicciones entre la plena integración en el sistema de explotación econó-mica y la exclusión de la atención sanitaria. Se recogieron datos de 2003 a 2005 y desde 2011 hasta 2012 usando métodos etnográfi cos y entrevistas en profundidad en un pueblo rural en México y en la ciudad de Nueva York, el principal destino de los migrantes.

Palabras claves: Abyectividad, acceso a los servicios médico, "ilegalidad", merecimiento, migración indocumentada, migración México-Estados Unidos, migrante, salud de los inmigrantes


«Illégalité», problèmes de santé et migration de retour: Le cas d'une communauté d’envoi des migrants située à Puebla, Mexique


Résumé : Cet article examine le cas de plusieurs travailleurs sans papiers forcés de retourner dans leur village natal au Mexique en raison des pro-blèmes de santé subis et qu’ils n’ont pas pu résoudre aux États-Unis. Leur statut «illégal» a compliqué la perspective d'un rétablissement complet et a par conséquent joué un rôle important dans leur décision de retourner au Mexique. Le non accès aux services médicaux, le souci constant de rester invisible face aux autorités locales, les conditions de travail exi-geantes et dangereuses, l’impossibilité d’avoir accès aux avantages so-ciaux traditionnellement réservés aux travailleurs, les salaires bas, ainsi que la séparation d’avec les membres de leur famille sont autant de fac-teurs qui contribuent à leurs problèmes de santé ou à l’aggravation de ceux-ci. Les entretiens menés avec les migrants, me ent en évidence les contradictions entre l'intégration complète dans le système d'exploitation économique et de l'exclusion aux soins de santé. Les données présentées dans ce e analyse, ont été recueillies de 2003 à 2005 et de 2011 à 2012 en utilisant des méthodes ethnographiques et des entrevues en profondeur dans un village rural au Mexique et à New York, principale destination des migrants en provenance de ce e zone.

Mots-clés : accès aux soins médicaux, adjection, l’ “illégalité”, santé des immigrants, le sentiment de “mériter”, migration clandestine, migration Etats-Unis - Mexique.

“Illegality,” health problems, and return migration: Cases from a migrant sending community in Puebla, Mexico

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