(C) Daily Yonder - Keep it Rural This story was originally published by Daily Yonder - Keep it Rural and is unaltered. . . . . . . . . . . Q&A: How Do Immigrants Navigate Rural America’s Healthcare System? [1] ['Olivia Weeks', 'The Daily Yonder', '.Wp-Block-Co-Authors-Plus-Coauthors.Is-Layout-Flow', 'Class', 'Wp-Block-Co-Authors-Plus', 'Display Inline', '.Wp-Block-Co-Authors-Plus-Avatar', 'Where Img', 'Height Auto Max-Width', 'Vertical-Align Bottom .Wp-Block-Co-Authors-Plus-Coauthors.Is-Layout-Flow .Wp-Block-Co-Authors-Plus-Avatar'] Date: 2023-12-15 Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week. Dr. Thurka Sangaramoorthy is a medical and cultural anthropologist and Professor at American University. Her new book, Landscapes of Care: Immigration and Health in Rural America, is a case study in the local transformations produced by globalization. In it, she asks what happens when a rural place gains a precarious immigrant workforce as its healthcare institutions are quietly undermined. Here, we talk about what she found. Enjoy our conversation about the rise of “new-destination” states and the aftermath of rapid demographic change in rural places, below. Olivia Weeks, The Daily Yonder: Can you start by telling me a little about yourself – what you do and where you’re from? And then I’d love to hear about how you got into this research at the intersection of rural healthcare and immigration. Dr. Thurka Sangaramoorthy: I’m an anthropologist and epidemiologist, and a professor at American University. I am an immigrant and former refugee whose family fled the civil war in Sri Lanka. My life and work are intimately intertwined, and I’m a scholar who conducts research on topics that are deeply meaningful and personal to me. I had long worked with Black and brown immigrant communities and their experiences with health and health care. My own experiences as well as those with whom I worked reflected stories of hope, resistance, and keen understandings of how institutions, including the state, inflicted enormous violence on their bodies, communities, and places where they lived. I’ve always felt that these narratives and perspectives needed attention. My interest in immigrant health in rural regions was fostered by work I had done as a public health practitioner working on disease outbreak investigations at the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia. I saw that in remote, rural places, complex issues related to immigration and the shuttering of public health services in rural regions were not understood. When I began my career at the University of Maryland, I was determined to focus on rural regions and began work on the eastern shore of Maryland. DY: How’d you choose Maryland’s eastern shore as your subject area? Can you describe its demographic makeup? TS: Maryland is a complicated place. It is essentially a suburb of our nation’s capital, Washington D.C., and seen as highly progressive. But it is also largely rural both in the west and east, where politics tend to be fairly conservative. It was a state where slavery was legal, and it was once highly dependent on enslaved labor, but also where there were several significant movements around labor and civil rights. This history is still present and visible on the eastern shore, where agriculture and other industries such as poultry and seafood dominate the landscape. The eastern shore faces many of the same challenges as other rural spaces in America and global locales such as population and economic decline, poverty, poor health, and environmental degradation. Currently, the nine counties that make up the eastern shore have a population of about 467,000, with about 7.5% of Marylanders living in the area. Some of these counties have majority white populations. However, there are substantial and growing populations of African Americans as well as immigrant communities in the region. The people that I worked with taught me so much about what I didn’t know, and the relations I hadn’t considered between rurality, health, and identity. DY: What are “new-destination” states? How have immigration patterns changed within the U.S. in the past 30 years and what import do those changes have for rural places? What economic trends are those changing immigration patterns responding to? TS: New-destination states are places without a long history of immigrant settlement. For years, immigrant settlement patterns in the United States have been rapidly changing. Significant flows of immigrant populations are shifting from more “traditional” areas to new-destination states. In 2000, for instance, two-thirds of immigrants lived in only seven states—California, New York, Texas, Florida, New Jersey, Illinois, and Massachusetts. But immigrant populations within these states have been slowly declining. At the same time, immigrant population growth rates in 14 other states, primarily in the central and southeastern U.S. (Alabama, Arkansas, Delaware, Georgia, Idaho, Indiana, Kentucky, Mississippi, Nevada, North Carolina, South Carolina, South Dakota, Tennessee, and Wyoming) were more than double the national average, and these mainly rural areas experienced rapid immigration growth. In 2019, there were 4.4 million immigrants in these new-destination states, nearly six times higher than in 1990. Global economic restructuring of trade, production, and finance has led to the growth of low-wage employment and driven immigration to these rural destinations. The loss of manufacturing jobs weakened the economic base of manufacturing-dependent rural communities and accelerated depopulation, including white flight. Rural areas became poorer and more racially diverse, which has resulted in further decreases in social and economic investments by the state and multinational corporations. In order to stem these population and economic trends, rural communities, like urban regions, have courted low-wage employers who increasingly rely on immigrants to provide labor. DY: You write that “despite rapid increases in immigrant populations in rural regions with crumbling health systems, we know very little about these communities, their experiences of care, and their ability to access and use health services.” Can you outline a few of the most surprising or important discoveries you made in the course of studying those communities? Residents receive healthcare at a mobile clinic on the eastern shore. (Photo courtesy of Thurka Sangaramoorthy) TS: Often, advocates, experts, and policymakers discuss the fate of immigrants in static, oppositional terms—whether society will embrace and integrate them, or reject and push them out. In rural Maryland (and perhaps much of rural America), where demographic shifts have been sudden and drastic, the lives of immigrants and rural community relations are complex and tenuous and challenge existing either/or assumptions about immigrant integration and exclusion. What goes unnoticed, unsaid, and unchallenged is that legal status has become the foundation of how we come to know immigration. On the eastern shore, legal status is critical to understanding the connection between immigration and rural health. But it is not the only determining factor that conditions immigrants’ experiences and perspectives with care. Those from Latin America, the Caribbean, West Africa, and Asia struggle to make a life in rural Maryland, and they have different experiences. There is no single story of immigration. Many rural health systems tend to be composed of loosely integrated and ill-coordinated public hospitals, community health centers, local health departments, and free clinics. On the eastern shore, individual providers themselves offer the only semblance of a safety net or health infrastructure. Essentially, safety-net patchworks and temporary, improvised care are the default in many rural regions throughout the United States. Existing systems to treat immigrants and the working poor in rural America, at their core, are inadequate, racist, and exclusionary. Immigrants and rural providers navigate this reality by engaging in complex social relations and mutual aid to care for themselves and each other. DY: What do you hope research on immigration to the eastern shore will cover next? TS: I sincerely hope that this inspires others to think about immigration and rural health differently. There is additional work to be done connecting various racialized and gendered labor systems historically on the eastern shore. It would be great to focus on particular labor markets and how they impact the health and well-being of rural residents. This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox. 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