TRANSBORDER HEALTH: HEALTH MANAGEMENT STRATEGIES OF IMMIGRANTS JOURNEYING FROM MICHOACAN TO MICHIGAN By Isabel Montemayor A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Anthropology - Doctor of Philosophy 2014 ABSTRACT TRANSBORDER HEALTH: HEALTH MANAGEMENT STRATEGIES OF IMMIGRANTS JOURNEYING FROM MICHOACAN TO MICHIGAN By Isabel Montemayor In recent years the increasing number of Mexican immigrants entering the United States, both documented and undocumented, has attracted great political controversy. It is a highly charged issue given the current economic, political and social situation on either side of the border, making for a particularly complicated experience for immigrants traveling from one country to another. This dissertation explores how the contentious socio-political arena of the Mexico/U.S. immigration relationship impacts the daily lives of those immigrants on the fringes of society. Unfortunately, it appears the rules and large scale institutional policies set in place by the U.S., such as those regarding health care and immigration, may fail to engage with the humanitarian issues of survival faced by one particular immigrant community. To date, studies addressing Mexican immigrant health needs have primarily focused on the border areas of the South and Southwest. However, given their increased population and new trends for geographical dispersion, Midwestern Mexican immigrants and their family members in Mexico, provide a window for understanding “new Hispanic growth communities” and how this underserved population navigates the health care and immigration arenas set in place by larger institutional policy. This research highlights the impact of governmentality in the form of macro-level institutional policy on the daily lives of transnational immigrants in three interconnected spaces, that is, while living in Mexico, while crossing the border, and while incorporating into U.S. society. The study made use of qualitative ethnographic interviews in both Michoacán and Michigan and participant observation in a transnational “Hometown Association” to answer the question: Given the individual, social and macro-level political barriers involved; what are the adaptive health management strategies used by a group of transnational Mexican immigrants? This study further investigates how these immigrants generate and employ agency in order to devise creative adaptations for addressing barriers to healthcare in their community, across various borders. I found that despite multiple social and structural limitations, Latino immigrants are individuals with strong family ties and a transnational identity. These characteristics along with a long political history between Mexico and the U.S. provide these individuals with a particular leverage in creatively adapting, understanding, and making use of limited resources on either side of the border to alleviate health related needs. Access to remittances, family members living in the U.S., and community efforts of a hometown association provide continued support and palanca for family members left behind in Mexico. Surrendering ones agency to coyotes and making life or death agentive choices during the border crossing experience allows for survival in a space free of standard communal resources. Upon incorporation into U.S. society an informal chain of information along with government sponsored public resources allow for undocumented immigrants to function while maintaining anonymity and a cultural link to Mexico that has proven to be useful in attending to health related issues. Copyright by ISABEL MONTEMAYOR 2014 For the brave men, women, and children who leave their families, suffer harsh desert conditions, and risk their lives in order to cross the Mexico-U.S. frontera. Los frutos de sus labores nos sostienen cada día. Ojala algún día, borders will cease to exist. y Para mi Madre y Padre, desde que abrí mis ojos por primera vez hasta la última línea de esta disertación, todo lo que he logrado es gracias al sacrificio, esfuerzo y apoyo de ellos. Si mi papa y mis abuelos no se hubieran hecho la cruzada hace tantos años, yo no estuviera aquí. v ACKNOWLEDGEMENTS I am indebted to those who assisted me in the development of this dissertation. Most of all, I am grateful to the immigrants from Orango, Michoacan living in Michigan and their family members in Mexico who shared their homes and stories with me. It goes without saying that the direction, guidance, support and multiple edits from my advisor, Dr. Linda Hunt, proved to be invaluable, especially during a series of unfortunate circumstances that could have made this dissertation unachievable. I have been blessed to be guided by such a knowledgeable, honest, and wise anthropologist. I am also grateful for the many contributions of my other committee members, Dr. Adan Quan, Dr. Heather Howard, and Dr. M. Isabel Ayala. I am thankful for the various departments and programs that have helped to fund my research and studies at MSU which include: The Dept. of Anthropology, The Center for Latin and Caribbean Studies, FACT Grant, IME Beca del Consulado Mexicano, The Graduate School (AGEP) and The King Chavez Parks Future Faculty Fellowship. Several key individuals provided me with encouragement and opportunities that have served me well: Lynn M. Curry, Dr. Tony Nunez, and Dr. Olga Hernandez-Patino, without their encouragement I would not have made it this far, Gracias. To my mother for her time and assistance throughout this process, eres un ejemplo de la mujer que quiero ser algun día. Finally, to Dr. Missy Soto and Dr. Christina Campbell I thank you for the long hours spent studying with me at libraries, coffee shops and study rooms, we are the few, we are the proud, we are the PhDs. I held it together because of you! vi TABLE OF CONTENTS LIST OF FIGURES……………………………………………………………………..ix KEY TO ABBREVIATIONS…………………………………………………………...x Chapter 1: Introduction, Living Transnationally……………………………………..1 Purpose…………………………………………………………………………………...4 Statement of Research Problem………………………………………………………...4 How the Study was Conducted………………………………………………………….6 Significance of Study…………………………………………………………………….7 Definition of Terms………………………………………………………………………9 Transnational…………………………………………………………………….9 Health……………………………………………………………………………10 Macro-level institutional reforms……………………………………………...11 Overview of Dissertation……………………………………………………………….11 Chapter 2: Framing the Question, Understanding the Emergence of the Hostile Environment………………………………………………………………………….....16 Introduction……………………………………………………………………………..16 Globalization……………………………………………………………………………17 Migration Theories & The Transnational Context…………………………………...19 Mexico/ U.S. Relations the Development of a Transnational Environment………...25 Citizenship & Identity Created Out of Transnationalism…………………………...33 Governmentality Entrenched in Institutions of Power………………………………36 Strategic Agency as a Means for Navigating Institutions of Power…………….…...40 Chapter 3: Methodology & Setting, Working Transnationally……………………...44 Why a Transnational Setting?........................................................................................44 Field sites………………………………………………………………………..45 Ethnographic Qualitative Research…………………………………………………...47 Phenomenological Research……………………………………………………………48 The Research Sample…………………………………………………………………..49 Data Collection Process………………………………………………………………...49 Community networking & snowball sampling……………………………….50 Participant observation (Migrant hometown association involvement & service as a community resource)……………………………………………...54 Semi-structured/open-ended interviewing…………………………………….59 Data Analysis & Write Up……………………………………………………………..60 Activist Anthropology…………………………………………………………………..61 Limitations………………………………………………………………………………63 Chapter 4: La Vida en Michoacán, Why People Leave & What They Leave Behind…………………………………………………………………………………...65 Who is Leaving Michoacan?...........................................................................................67 vii Leaving Michoacan: Conditions & Infrastructure at the International & Local Level……………………………………………………………………………………..69 How do Residents fill the Void? A Transnational Relationship of Remittances…...74 The Health Situation of Those Who Stay Behind: Case Studies in Strategic Agency…………………………………………………………………………………..77 Strategic agency at the individual level……………………………………….78 Strategic agency at the family level……………………………………………86 Strategic agency at the community/transnational level………………………96 Transnational Strategic Agency: Realities from Michoacán……………………….102 Chapter 5: La Cruzada/The Crossing, Surrendered Strategic Agency in the Land of Liminality……………………………………………………………………………...104 Pushing People to Extremes…………………………………………………………..109 Shifting Agentive Strategies in Order to not be Left Behind……………………….113 Shifting Agentive Strategies in Order to Survive……………………………………122 Starring Death in the Face in Order to Survive the Cruzada………………………129 Chapter 6: Navegando Michigán, Piecing Together Resources in a New Culture of Medicine………………………………………………………………………………..132 Navigating Health Care Locally at the Individual and Proxy Levels……………...135 Making sense of the pharmacy……………………………………………….136 Navigating out of pocket care………………………………………………...143 Utilizing government funded care options…………………………………...146 Utilizing complimentary & alternative medicine……………………………150 Navigating Health Care Transnationally at the Individual and Proxy Levels……152 Consulting doctors via telephone & utilizing medicine from Mexico……...153 Seeking treatment in Mexico…………………………………………………156 Navigating health care locally at the community level……………………...164 Strategizing Agency Locally & Transnationally in Order to Navigate Health Care…………………………………………………………………………………….169 Chapter 7: The Deportation Center, What this all Means for Families across Borders…………………………………………………………………………………172 Conclusions: What we have Learned about how these Individuals Manage Health…………………………………………………………………………………..175 Agentive strategies…………………………………………………………….176 Cultural citizens……………………………………………………………….177 Proactive agents……………………………………………………………….178 Health seeking strategies……………………………………………………...179 Where to go from Here?................................................................................................181 REFERENCES………………………………………………………………………...184 viii LIST OF FIGURES Figure 1: Community Gathering………………………………………………………57 Figure 2: A posada……………………………………………………………………...57 Figure 3: Serving as Madrina………………………………………………………….59 Figure 4: A panoramic view……………………………………………………………67 Figure 5: Alondra Soto....................................................................................................84 Figure 6: Abandoned casa de salud..…………………………………………………..95 Figure 7: Note…………………………………………………………………………..95 Figure 8: Letter thanking Grupo San Judas………………………………………...100 Figure 9: A letter sent from a young woman with Lupus..........................................101 Figure 10: Yadira Segovia and others……………………………………………….168 Figure 11: Pozole.……………………………………………………………………..168 ix KEY TO ABREVIATIONS CAM-Complimentary and Alternative Medicine FACT-Families and Communities Together Grant ICE-U.S. Immigration and Customs Enforcement IMSS-Instituto Mexicano de Seguro Social [Mexican Social Security Institute] IRCA-Immigration Reform and Control Act of 1984 ISSSTE-Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado [The Institute for Social Security and Services for State Workers] LEP-Limited English Speaker NAFTA-The North American Free Trade Agreement S-CHIP-State Children’s Health Insurance Program x Chapter 1: Introduction, Living Transnationally Fernando Segovia stares at the picture of his mother sitting on the small altar created for her novena [nine nights of praying the rosary]. He sits and stares. He is helpless and full of melancholy knowing full well his mother died thousands of miles away in rural Michoacan while he and his two siblings scrambled to find the necessary money to save her life; a cause that proved unfruitful in the end. This solemn, silent conversation between Fernando and his deceased mother occurs each night after 40 adults and 15 children leave his newly purchased home in a Grovenburg1, Michigan. For nine nights the group gathers in order to help the soul of the faithfully departed find her way to heaven crossing the boundaries of physical life into the life of the deceased. The rosary serves as a type of saving grace for the spirit of the dead, a type of healing for those who are grieving and a link between those praying in Michoacan and those praying in Michigan, at the same time, for the same reason, two worlds apart. A cross made of individual daisies and white flour is placed in front of the altar and on the last day each daisy is scooped up with the flour by a family member. One lifting the arms, another lifting the head, another the legs and finally the youngest son lifting the heart and burying it in a box. These family members, so many thousands of miles away, are physically participating in the spiritual burial of Doña Lucero. These actions are not symbolic, they are real and allow the family to physically participate in the burial. According to Yadira Segovia, Fernando’s wife, “se levantan la cruz como tradición para ayudar a enterrar a la persona que fallecio, asi lo hacen en Orango” [They pick up the cross as a tradition in an effort to help burry the deceased person, that’s how they do it in Orango] Fernando misses his mother, not the thin fragile woman who could no longer see or hear during her last days, a woman whose body was covered in cancerous tumors. He misses the woman who hugged him and cared for him four years ago when he was deported back to his native Orango, Michoacan. Fernando waits in silence for the ability to physically say good bye to his mother, an opportunity that did not come and never will. He did what he could to save her life in another country and restore her to good health. He put his faith in a health care system he did not understand and depended on his younger siblings, in Mexico, to make the appropriate choices regarding his mother’s care. Fernando has traversed physical boundaries various times by choice and by force, each time becoming more and more entrenched in a network of transnational migration that is enmeshed with an ever globalized world. Fernando and his inability to emotionally heal after a devastating health situation in his family serves as an example of the millions of undocumented immigrants who must navigate a bidirectional system, cadena [chain]of resources and knowledge in order to strategically survive. To understand Fernando and his familía [family], their sacrifices and strategies for survival, between two worlds that are linked, we must start from the beginning… 1 Grovenburg, Michigan; Orango, Michoacan; Grupo San Judas; and all other towns and Churches are pseudonyms used to protect and guarantee the anonymity of those individuals involved in this study. 1 As a Mexican-American I have always been interested in Mexico-U.S. relations; the contentious relationship between lopsided economies, the hostile border environment and most importantly the individuals connected to both countries. When I began this study, I spoke candidly with many of my undocumented friends, like Fernando Segovia, about life for them living so far away from their native Mexico. I quickly became aware of the daily challenges they encountered accessing certain public resources. My friends began to ask for my assistance regarding issues related to health, such as translation of medical forms and transportation to clinical visits. The health related issues facing these individuals were clearly exacerbated given their undocumented status, limited English proficiency, absence of formal health insurance and inexperience with U.S. health care. I began to wonder what accessing health care might be like for someone in a new country and how those health experiences may be compared to the experiences these individuals had in their native Mexico. Throughout the nation, Mexican immigrants have become an overwhelming necessity in the agricultural and service sectors; their presence is and has been noticeable in the un-skilled and semi-skilled labor industries, especially since 1990 when Mexico suffered an economic crisis leading to a significant wave of emigration (Zuniga & Hernandez-Leon, 2005). The Mexican immigrant labor force in Grovenburg, Michigan, one of the sites for this study, has fast become very valuable to the local economy. The area is home to a growing population of Mexican immigrants. The 2000 United States Census reported that approximately 2.2% of the 3.3% of Latinos living in Michigan are of Mexican origin (U.S. Census Bureau, 2000). A large majority of these Mexicans are recent immigrants and have followed the waves of migrants that first arrived to Michigan 2 through the Bracero program (a contract labor agreement between Mexico and the U.S.) and are from towns in eastern Michoacan, most notably Orango. Despite being among the fastest growing populations in the Grovenburg area, knowledge about the health seeking strategies of this group on either side of the border and the impact of macro-level forces on their lives is limited, as they make choices regarding migration and health for their families and themselves. The research presented in this dissertation is timely, given the recent contentious changes in U.S. health care and the debates surrounding unresolved immigration reform. Difficulties in accessing healthcare are real issues faced by millions of Americans and Mexicans living in either country everyday, these issues are compounded further for marginalized populations, especially undocumented immigrants in the U.S. and the rural poor in Mexico. In order to better understand the human side of migration and health care I examine transnational lives of those confronted by such challenging situations. The problem of accessing health care for example is made even more difficult given the health care crisis that currently plagues this country, with upwards of 47 million uninsured people in the U.S. today (DeNavas-Walt, Proctor & Smith, 2007). By U.S. Census Bureau estimations, Latinos compose the largest uninsured population in the U.S., with about 34% uninsured in 2006 (DeNavas-Walt et al., 2007). It is estimated that there are currently 11.5 million Mexican immigrants living in the U.S., with as many as 50% undocumented, many of whom are likely uninsured (Batalova, 2008). Despite the well-known size of the Mexican immigrant population, little is known about their strategies for addressing their obvious health care needs both in the United States and in their Mexican sending communities, especially if they are undocumented (Parra et al., 3 2006). We do, however, know that immigrant groups often keep constant interaction with their country of origin in an effort to find solutions to their problems and maintain network ties (Bastida, Brown, & Pagan, 2008). I posit that the families in the present study are involved in a unique type of transborder living that transcends bounded ideas of flow and process. Their stories may create an awareness of deficiencies in current systems of health care and the ways people with only limited resources adapt. This awareness can be translated to other marginalized communities of immigrants living in the U.S. with sustained connections to their sending communities. Purpose The purpose of this dissertation is to investigate the real-life health experiences and adaptive health management strategies utilized by Mexican immigrants and their families on both sides of the border, in order to shed light on how forms of governmentality found in macro-level institutional policies impact daily lives. Currently there is a great deal of research on both the topics of migration and health care for those living on either side of the border but rarely do any of these studies document how these themes impact the lives of individuals living in a transnational context. Statement of Research Problem In recent years, the increasing number of Mexican immigrants migrating to the United States, both documented and undocumented, has attracted great political controversy and significant media attention (Chavez, 2008). It is a highly charged issue given the current economic, political and social situation on either side of the border, making for a particularly complicated experience for immigrants traveling from one country to another. Mexicans have had a long historical link with the United States due to 4 labor relations and proximity, thus marked by waves of immigration over the years (Acuña, 2007). Mexican immigrants are confronted with a host of difficulties as they emigrate out and immigrate into one country or another, whether by choice or force. In addition undocumented Mexican immigrants, specifically, face a myriad of trials and limitations in gaining access to public resources due to their liminal status which may include lack of medical insurance, social security numbers, and stable sources of employment (Carillo, Trevino, Betancourt & Coustasse, 2001). Those who left Mexico shared with me their reasons for leaving and the situations they left behind, how their own family members also face a multitude of challenges in accessing health care in Mexico. Such challenges include lack of child care, high costs of transportation, and a structural deficiency in available sources of care (Lakin, 2009). I argue that the united links between persons on either side of the border assist in confronting some of the macro-level influences challenging the management of ones health. In this dissertation I will explore the creative adaptations of this transnational population by addressing the question: Given the individual, social and macro-level institutional barriers involved, what are the adaptive health management strategies used by a group of transnational (un)documented2 Mexican immigrants, who live in Michigan and their families living in Michoacan. I examine the health experiences of people while living in Mexico, as they cross the border and while incorporating into U.S. society? The goals of this dissertation are to 1.) Document the emergent health issues and strategies 2 It should be known that a number of individuals in this study population have acquired residency or citizenship over the years through marriage and family reunification, while others have migrated without authorization and have remained with undocumented status. Therefore some of the individuals in this study are documented and some are undocumented but all have a tie to the same hometown in Michoacan. I use “(un)documented” at times as a means for identifying both sets of individuals simultaneously throughout the study. 5 employed for addressing health concerns within a community of transnational (un)documented Mexican immigrants. 2.) Identify how marginalized populations, like (un)documented immigrants in the U.S. and the rural poor in Mexico, understand and utilize their agency to address the needs of themselves and their families when faced with political and social barriers. 3.) Explore how immigration policy and migration experiences frame the lives of these individuals and affect the choices they make regarding their health and that of others in their transnational community. Each of these goals are intended to shed light on how Mexican immigrants with limited agency utilize innovative means to counter the various forms of governmentality, that influence their daily lives. How the Study was Conducted In order to accomplish the goals set forth in this dissertation I designed a study that is both empirical and analytical in nature. The time I spent working on establishing rapport and collecting data with this community have supplied me with a breadth of stories and experiences that clearly paint a picture of the “human” side of the immigration and health care debates. From one undocumented woman’s struggle and triumph over Uterine Cancer with no health care coverage, to the plight of a young man with diabetes who ultimately returned to Mexico for medication and treatment; the stories presented throughout this document are real and stand as a testimony to systems and institutions that have failed to take into consideration the health needs of the most vulnerable. Through this ethnographic research, I argue that despite limitations imposed by a structurally hostile environment, Mexican immigrants are individuals with strong family/community ties and a transnational identity that provides their family members 6 and them with a particular leverage in creating additional options for care on both sides of the border in order to survive. Through the narratives and experiences of these Mexican immigrants and their families on both sides of the border the study offers insight into the process of migration, as well as the health needs, resources and strategies of this particular transnational population. To conduct this study I examine sustained cross national transborder ties through the use of semi-structured interviews and participant observation. While conducting the study I lived in the Midwestern city of Grovenburg, Michigan, and traveled several times to the rural Mexican municipality of Orango, Michoacan. My own transnational experiences with this group, across locations, contributes to a deeper understanding of how the movement of goods, knowledge, resources, capital and people functions in daily interactions Throughout the following chapters I take a critically interpretive phenomenological approach, which allows me to examine the positionality of those involved in my study through their own experiences: how they understand their particular situation or give meaning to their circumstances, and to situate these experiences within a larger context of unresolved institutional reform. The fieldwork I conducted provides ethnographically detailed insights into the lives of these marginalized individuals, how they navigate constantly changing policies; systems; programs and information in an effort to adapt as well as address the health care needs of their families and themselves. Significance of Study This dissertation highlights the impact of macro-level institutional policy on the daily lives of those immigrants on the fringes of society I use health as a window for 7 understanding the unique adaptive strategies these individuals utilize in order to survive. Unfortunately it appears, the rules and large scale institutional policies set in place by the U.S., such as those regarding health care and immigration, may fail to engage with the humanitarian issues of survival faced by this particular immigrant community. This dissertation contributes to the literature on health care for the marginalized by illuminating how a growing underserved and unacknowledged population makes sense of and navigates the health care arena set in place by larger institutional policy, on both sides of a political border. The research ultimately sheds light on how structures and individuals contribute to how health is managed within a complex transitional community. This research also yields important information on emergent health issues, health seeking strategies and migratory networks used by an often neglected, transmigrant population of documented and undocumented Mexicans. There is currently a great deal of research and public discussion about the status of health and health needs for minority populations throughout the country, which has produced a burgeoning literature on the limits of the health “safety net” and its impact on special populations in the U.S. (See for example: (Becker, 2004; Becker, 2007; Cunningham, Baker, Artiga, & Tolbert, 2006; Unequal Health Outcomes in the United States, 2008)). This study seeks to contribute to the literature in a unique way. To date, studies addressing Mexican immigrant health needs have primarily focused on the border areas of the South and Southwest, most notably California and Texas and often concern themselves with immigrant groups from more traditional sending communities like Zacatecas and Guanajuato. (See for example: (Chavez, Flores & Lopez-Garza, 1992; Guendelman & Jasis, 1990). “While much of the Hispanic population is concentrated in 8 areas that historically have had a large Hispanic population, smaller urban and rural areas that previously had relatively few Hispanics are now experiencing very high rates of growth” (Cunningham et al., 2006, p. 1). Given their increased population and new trends for geographical dispersion, Midwestern Mexican immigrants and their family members remaining or returning to their sending communities in Mexico, provide a window for understanding “new growth communities” within a health related context. In addition, these immigrants’ strategies provide insight regarding the limitations of health care policy in addressing the needs of the marginalized, especially from a medical anthropological perspective. The specific intention of this dissertation is to document the effects of unresolved institutional reform on the daily lives of (un)documented Mexican immigrants, as they navigate a transnational environment between Grovenburg, Michigan and Orango, Michoacan. By using individual narratives extracted from semi-structured interviews conducted both in the United States and Mexico, as well as community participation in this population’s Hometown Association, I paint a picture for how health plays an integral role in the daily lives of this population and the challenges involved in addressing certain health issues. Definition of Terms Transnational. I use of the term transnational, or transmigrant throughout this dissertation to describe Mexican immigrants both documented and undocumented with sustained ties to the United States or Mexico comes from Nina Glick-Schiller, Linda Basch and Cristina Blanc-Szanton’s definition in Transnationalism: A New Analytic Framework for Understanding Migration (1992). Here the authors call for a 9 reconceptualization of prior notions of immigration and describe transnationalism as, “a process by which immigrants build social fields that link together their country of origin and country of settlement”(p.1). Furthermore the authors describe transmigrants as those who, “develop and maintain multiple relations-familial, economic, social, organizational, religious, and political that span borders”(p.1) such activities speak volumes about the human ability to successfully navigate new settings and systems of change. Lynn Stephen (2007) takes this notion one step further and identifies these individuals as “transborder,” meaning individuals who have crossed multiple ethnic, racial, economic, class, national, technological and communication boundaries throughout the entire migration process. Although this term may adequately serve as a reminder of the challenges involved in “crossing multiple borders” I believe “transnational” or “transmigrant” may serve the purposes of this study more appropriately as these terms draw specific attention to the sustained ties that individuals maintain across distance, time and space. Health. Although migratory networks and health seeking strategies are themes that I develop throughout the dissertation, it is important to define term “health” within the context of this particular study. Here I follow the definition supplied by The World Health Organization, which has not been amended since 1948. Health, according to the WHO is, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”(1946, p.100). Throughout this study I take into consideration the emotional, physical, and social well being of the individuals involved. Any barrier to achieving optimal health may be considered a health concern, including but not limited to injury, disease, social isolation, stress induced by work, migration, and 10 immigration status. I use “health” throughout the dissertation to mean holistic well-being, drawing attention not just to the physiological components but also the social indicators contributing to poor health outcomes within this particular population. Macro-level institutional reforms. Throughout this dissertation I also reference macro-level institutional reforms. In the broadest sense I am referencing those policies and programs imposed at the national level and international level that have or are, directly and indirectly affecting the lives of the subjects involved in this study. Many of these reforms are described in detail throughout the subsequent chapters of this dissertation. The North American Free Trade Agreement for example, current immigration policy, The Bracero Program, Seguro Popular, Medicaid, just to name a few. Overview of Dissertation In the following paragraphs I have supplied brief descriptions of each of the subsequent chapters in this dissertation, to clarify the trajectory of the project. In Chapter 2 “Framing the Question, Understanding the Emergence of the Hostile Environment,” I position my work within the relevant anthropological, migration and health literature, paying close attention to certain themes that frame the current situation for Mexican transnationals. I describe globalization and how certain processes that develop out of this ideology have given way to migration chains from Mexico into the U.S., providing a framework for understanding transnational lives. I draw specific attention to the various international policies and institutional reforms imbedded throughout the historically contentious Mexico-U.S. relationship that play a part in the daily lives of these individuals. In Chapter 2, I also describe the notion of “governmentality” and it’s 11 presence in institutional structures aimed at controlling individual action through the limiting of resources. Moreover, the chapter introduces the concept of “agency” and the various forms of agency used to combat governmentality in its institutionalized forms. In Chapter 3 “Methodology & Setting, Working Transnationally” I describe the transnational setting of this research. I describe Grovenburg, Michigan and Orango, Michoacan, their connection to one another and why these locations serve as appropriate sites for examining transnational health seeking strategies. I describe why a transnational setting serves as an appropriate forum, given the patterns of movement and sustained interaction that create useful resources within this community. I give a brief history of my first interactions with key informants who served as guides and provide examples of how one navigates between fluid spaces. I also give an overview of the people involved in my study and how they arrived at their current locations (i.e patterns of migration). In this chapter I also explain how I developed rapport with families in both locations, and used networking on either side of the border to further facilitate entree into this transnational community. This chapter also describes my methodology: how the study was designed and executed, how I developed the interview protocol, how I became involved in the hometown association established by this group and the types of work the group accomplishes. This chapter also describes my method for analysis. In Chapter 4, titled “La Vida en Michoacán: Why People Leave and What They Leave Behind,” I begin to explore the complex global process of migration, contextualizing some of the transnational needs, resources and agentive strategies for survival found among a group of Michoacan residents with ties to Mexican transnational immigrants living in the U.S. I examine the conditions that have led to the exodus from 12 Orango and the void that migration produces for those left behind, and what led them to their strategic health choices, when there are institutional barriers to care. I provide an understanding for why and how this small town in Mexico has become linked to the United States by transnational means considering various forms of agency: at the individual, family/proxy and communal/collective levels. To illustrate these points I share the health narratives of several families with a strong connection to the United States and consider how they made strategic choices in order to acquire certain health related resources. I highlight the factors taken into consideration, limitations on where and how people seek care in Mexico, and how needs are best fulfilled through a complex network of resources and knowledge found at all agentic levels. In Chapter 5, titled “La Cruzada/The Crossing: Surrendered Strategic Agency in the Land of Liminality,” I describe the illegal migration process and some of the health concerns involved. While the previous chapter describes the conditions for why people leave Orango and what life is like for those who stay behind, this chapter describes how people leave, that is how they cross the border into the United States. I provide a brief description of how some failed policy reforms have exacerbated the costs and difficulties of desert border crossing, exacerbating the dangers of crossing into the U.S. In order to survive the harsh conditions of the desert border and the challenges of crossing illegally, the undocumented immigrants in this study formed unique adaptive responses such as reorganizing their agentive networks and strategies throughout their journeys, as options and resources changed. I highlight the risks involved and dangers in crossing. I develop the idea of surrendered strategic agency; that is the active choice to surrender ones decision making capabilities to proxy agents who have more knowledge, power and 13 experience in crossing the border illegally, i.e. the coyote [human smuggler]. The case studies in this chapter demonstrate how, in a state of liminality, individuals adapt, respond, and survive. In Chapter 6, titled “Navegando/Navigating Michigán: Piecing Together Resources in a New Culture of Medicine,” I take the reader into the live of those immigrants who have made it across the border and live in Michigan. Here I describe the various health care options available in the U.S. and how new Mexican (un)documented immigrants, with limited resources, traverse various boundaries in order to seek care. I present specific medical encounters as case examples for understanding the passive and active forms of strategic agency used by transnational immigrants in addressing matters of health. The examples in this chapter illustrate the types of resources used by immigrants in Grovenburg, Michigan at the local and international level in order to gain access to health care and address particular health care needs. These examples demonstrate how the community of immigrants in Grovenburg has maintained a link to Orango; a transnational agentic strategy that only functions if the links are also maintained at the individual, proxy and collective agentive levels. In Chapter 7, titled “The Deportation Center, What this all Means for Families across Borders” I describe how transnational immigrants and their families use interconnected relationships developed out of globalization, to creatively adapt. I consider how this study serves as a case example of what health care management is like for (un)documented poor Mexican immigrants living in the U.S. and what accessing health care is like for the marginalized rural poor in Mexico. I call for additional studies to be conducted in non-traditional receiving states so as to better gauge how pockets of 14 Latinos in new growth areas like Michigan, are continuously affected by large scale institutional reform across the nation. I also call for improved efforts by local health departments in both Mexico and the U.S. to address the specific needs of the marginalized. The examples provided throughout this dissertation are but a few of the multitude of challenging situations immigrants face while incorporating into society, their strategies for overcoming such challenges provide great insight regarding the human capacity to creatively adapt. 15 Chapter 2: Framing the Question, Understanding the Emergence of the Hostile Environment On my first research trip to Orango, I sat in my seat on the tiny airplane that carried me through the stormy night sky. I held the little 8 year old boy whose mother had entrusted to me to accompany across the border. He was headed to Michoacan on a mission considered of great importance to his mother. He would be meeting his grandfather, uncles and cousins for the first time in Orango. The turbulence was strong and our heads almost hit the ceiling with every bump. Although I was scared and instinctively grabbed the rosary in my pocket I reassured little Miguel that we would be okay and I looked out the window. Staring down at the vast landscape of the sierra Madre Mountains, I remembered something that came to me each time I traveled by air across Mexico, “What a luxury I have. How many people die crossing these mountains and desert, in an effort to make it across the Mexico-U.S. frontera [border]?” I looked at Miguel sleeping on my shoulder and thought of the young father from his community in Michigan, named Fernando Segovia, whoI had recently visited in a detention center before his deportation. I imagined he was probably already contemplating his next brinco [jump] back across the border. The brinco was something little Miguel’s mother, aunts, uncles, cousins and friends had done on many occasions. That reality was something little Miguel would never have to suffer as a U.S. citizen. What a luxury indeed! Introduction It’s unfortunate that what often gets lost in discussions regarding the formal relations between the neighboring countries of Mexico and the U.S. are the lives of individuals that transcend the border in either direction, everyday, such as little Miguel and others that make up his community. In order to explore the impact of macro-level processes like globalization and migration on marginalized individuals, I examine the specific health care strategies used by a group of transnational Mexican immigrants as they live out their lives in this context. Throughout this dissertation I argue that policy is developed and assessed out of macro concerns neglecting the micro impact on real lives of individuals. Exploring the unique health management strategies of a transnational population serves as a window to understand the nexus of where and how global processes converge at the individual and community level. In order to examine those real life impacts I will begin by considering the policies and macro frame in context. 16 Globalization, for instance, includes the flow and movement of people and goods across borders, however with globalization comes forms of governmentality such as institutional structures used to regulate and control that movement. Although we know a great deal about globalization and its many forms we lack a clear understanding of how the regulatory measures involved in managing globalization impact marginalized populations, and how those populations navigate those structures. Information on the various forms of agency and social fields where individual choices take root can yield great insight into the broader impact and influence of globalization and other macro level processes. The global scope by which people move across boundaries, the acceptance or rejection of such movement by nation states, and the environment created out of such global processes is played out in the strategic daily choices, interactions and limitations of individuals and small communities at the micro level. Globalization Globalization, a modern term but very old concept can be described as “the widening, deepening and speeding up of worldwide interconnectedness in all aspects of contemporary social life” (Held et al, 1999, p.2). Globalization encompasses a myriad of processes and actors all interlinked on a global scale. It is a process that is tied very much with understandings of changes in time, space, and human interaction. The connection of human activities, that is tied through geographical locations, stands as the cornerstone to globalization; creating environments where distant actions and events impact life at the local and regional level (Tomlinson, 1999, p. 9). In general, globalization is not just about traversing geographical boundaries nor is it solely tied to neoliberal ideology or political economic models; globalization 17 includes a critical human element. As Renato Ortiz (2006) argues, globalization is much more than a transverse process tied to material things, it is a world process inherently rooted in cultural diversity. In this same vein the situation of individuals and the choices they make to prosper in a global context serve as examples of the proliferation and movement of ideas, capital, money, goods, knowledge, and trade. According to Collier and Ong (2005) globalization can be viewed as a problem space where anthropological questions take root and intersect with macro-level processes. This dissertation is situated within a globalized framework and posses an anthropological question regarding transnational immigrants or those living between two spaces: What are the unique adaptive strategies used by this specific transnational population to address health needs in a globalized world and what do these strategies tell us about the macro-level processes and unresolved institutional reform involved? It is therefore the responsibility of social scientists to take as Munck (2008) puts it a “Southern approach” where interactions with sending states are valued as much as interactions with receiving states, especially when dealing with globalization and related phenomena like migration. Fred Dallmayr (1998) argues that the globalized world functions in an interconnected manner and is driven by a western ideology. He contends that the voices of others throughout the world with whom we are intimately connected and whose lives are impacted by such global processes are often neglected. Although from a global standpoint people cannot always move freely from one bounded geographical state to another, with the eminent presence and normative power of globalization, people are inherently interconnected through the use of networks, trade, technology and knowledge 18 across space and time. Increasingly, people are breaking with the confines of political boundaries and physically moving or migrating from one geographical location to another, both legally and illegally, introducing a host of new challenges to managing a globalized world. Governments have taken great strides to manage this movement through policies and structures, that can be found at all levels of society, such as immigration law and health care reform. According to Munck (2008), international migration is a type of revolutionary globalization process, affecting political systems, economic structures and notions of culture (p.6). The dynamic flow of goods, ideas, knowledge, capital and money freely across borders is enmeshed with the movement of people and their cultural understandings. Globalization and international migration serve as reciprocal agents in an era where individuals and communities are dependant on networks, movement and change across boundaries. Migration Theories & The Transnational Context Modern international migration, a globalized process in and of itself, is complex and diverse. Theorists in various disciplines have endeavored to draw specific theoretical models for the movement of people from one place to another. Several well known theoretical models have developed to explain the reasons for human migration. The NeoClassical/Push Pull Model for international migration is based on economics and economic needs of individuals as they decide to move from low wage areas to high income areas producing a system of absorption by high wage earning countries and a system of dispersion for low wage earning countries (Grigg, 1977). In this model individuals are viewed as independent agents who compare costs and benefits, in deciding to leave one country and migrate to another (Savitri, 1974; Borjas, 1989). This 19 model of push-pull factors contributing to individual decisions about migration is limited in that it does not take into consideration alternative reasons for continued migration to metropolitan areas which have high levels of un-employment. Neither does it consider other external macro level factors that potentially have a bearing on migration patterns such as economic recessions and amnesty programs. The Historical dependency model/World system model is another other important model used over the years to explain the reasons for international migration. With roots in Marxist Political Economy this theory focuses on the study of economics and capitalism at the global scale. Wallerstein (1984) argues that due to 16th century industrial expansion only one global economic system exists: the World System. Since that time the world has established a type of pecking order where core nation states are in a constant process of accumulation of capital. Core countries are more technically advanced and have high labor demands for the production of complex goods, they feed off of the cheap labor, raw materials, and agricultural products supplied by the periphery. This unequal economic exchange results in a constant friction between core and periphery countries. Capitalist formations, or interactions that support advanced and traditional sectors in the periphery, are created to serve the needs of the other capitalist formations. These unequal relationships between poorer countries and richer countries essentially lead to the inability for underdeveloped countries to develop (Amin, 1974). Although this theory takes into account macro-level contributing factors, such as the capitalist economy as motivating nation states to spearhead the migration process, it lacks consideration of the micro-level individual components that may drive individual choices to stay in their country or to leave. 20 In Brettell and Hollifield’s (2000) introductory chapter, “Migration Theory: Talking Across Disciplines” the authors posit that most social scientists do not share the same paradigm regarding migration theory and that there is a common separation of those social scientists who take a top down macro centered approach and those who take a bottom up or micro approach. This divergence has led to a lack of a more multidisciplinary approach in the study of migration, which can mean either very individual-centered hypotheses that neglect the influence of larger institutions/structures or the reverse. Portes & Borocz (1989) juxtapose contemporary migration theory among traditional theoretical approaches and describe migration theory as ever evolving in a world of theoretical naming. The authors draw attention to the way in which social scientists are constantly trying to identify the new migratory processes but by the time this has happened the process has evolved and must then take into account a variety of new contributing factors. In essence migration is driven by more than push-pull factors and more than historical links, it is a body of networks and systems that are very much social in nature, formed out of contemporary and historical relationships; institutions; cultures; and the strategic choices made by individuals and communities. Massey et al. (1993) presents a short description of the various accepted migration theories used in the social sciences, some micro-level centered, some macro-level centered, some network focused and other more recent theories more institutionally, structurally and politically motivated. Massey’s description demonstrates the variance in social scientific migration theory. According to Zolberg (1989) as migration patterns tend to change so to do the theories that accompany them. 21 Still, with the changes in migration theory and development of new theory, some fundamental characteristics remain the same. Most new theories are historical, structural rather than individualistic with special emphasis on capitalism and the state influence, globalist in nature, and critical in that they are concerned with the consequences of international migration on sending/receiving states and individual migrants themselves. Zolberg explains that, "the historicization of migration theory implies that theoretical concerns and emphases must be modified in the light of changing social realities"(p. 404). Such social realities can include institutional policy which has a direct effect on human lives. In essence there exists a constant “tug-of-war” between institutional policy aimed at realizing specific socio-political agendas and the individuals who are constrained by such institutions (Shrestha, 1987). These policies and constraints in turn influence individuals’ migration behavior, e.g. urban industrial policies and their contribution to rural to urban migration, but are not always aligned with population needs and aspirations. People living across physical borders link their lives through networks and people, regardless of institutional policy or because of it. Actual institutional policies and control strategies deployed by receiving states often seek to limit immigration; unfortunately many of these strategies do not coincide with or compliment global changes in migration patterns (Schuck 2000). The lives of working class immigrants are no longer fragmented into two separate spaces; instead given modern transportation and communication technologies, their lives are continuously linked across/through borders (Gordillo, 2010; Hobbs & Jameson, 2012). This unification of spaces creates a complex and new environment for the immigrant. Immigrants are now readily able to operate and 22 function in a dual capacity attending to the needs and obligations in both their new homes and sending states. In order to address this circularity and movement between spaces, that can be found in migration studies, theorists have hypothesized a transnational option which takes into consideration the identity construction and brokering of hard boundaries often faced by migrants (Massey & Sanchez, 2010). Portes et.al.(1999) define transnationalism as "occupations and activities that require regular and sustained social contacts over time across national borders for their implementation" (p.219). This circular movement of people is affected and determined by both the individual’s networks and the macro-level policy that influences both positively and negatively such movement (Portes et al, 1999). Interrogating transnationalism from “above” and “below” allows for a deeper understanding of the intricacies involved in human movement (Guarnizo & Smith, 1998). In addition to analyzing macro level policies and individual decisions, it is important to dissect how we have gotten to where we are with regard to globalization and migration. Considering the historical context and prior links involved in creating a transnational relationship contributes to a more thorough understanding of the current political climate for Mexican immigrants. My study builds on these hypotheses, examining individual micro-level strategies for navigating migration and health situations in the context of macro-level institutional policies. This study will combine a migration systems theory with a transnational approach. With origins in anthropology and sociology these models are both interdisciplinary in nature. In The Age of Migration , Castles and Miller (2009) present a comprehensive overview of the various predominant theories relating to migration. They posit that more often migration is being tied up with macro, micro, and meso influences and that there is a constant cyclical exchange and interlinkage 23 between countries. “Migration systems theory suggests that migratory movements generally arise from the existence of prior links between sending and receiving countries based on colonization, political influence, trade, investment or cultural ties” (p.27). Throughout Mexican-U.S. history there have been times of great human migratory waves for various reasons, in addition there has always existed a consistent flow of goods and resources from one country to the other. Colonization such as during the signing of the Treaty of Guadalupe Hidalgo led to ceded territories and an entire population being reassigned citizenship status. No longer considered Mexicans these individuals became American when the border crossed them. Political influences such as the bi-lateral Bracero guest worker programs led to the incorporation of thousands of Mexicans who came to work temporarily during war-time necessity in the U.S.. Many of these Braceros remained in the U.S. after their contracts were up and brought their family members across the Rio Grande to join them. With implementation of NAFTA trade practices had a direct/indirect impact on migratory flows as people from rural farmers in Mexico were outsourced by large U.S. agribusiness and migrated to the border region to work in Maquiladoras [sweatshops] and further north into the U.S.. In addition, investment has played a large part in Mexico U.S. relations as the U.S. has traditionally invested a great deal of money in its neighbor to the south. Moreover the shear volume of Mexican immigrants living in the U.S., over 12.7 million, creates an environment of strong cultural ties that further solidifies Mexico U.S. relations. Taking all of these policies and processes into account one can only begin to understand how individual lives are impacted. Fawcett & Arnold (1987) suggest examining the migration system in terms of a constant “flow and counter flow” of people, where all factors, including places of 24 destination, reasons for movement, and place of origin are constantly in relation to one another over time. Mexico/ U.S. Relations the Development of a Transnational Environment The ties that we see between Mexico and the U.S. are bound by a long history of labor migration that carries through to today. The contentious relationship between these two countries serves as an example of Globalization and global processes at work. The two countries share a physical border and immigration has for the most part been cyclical and unidirectional due to uneven economies. The historical relationship between these two countries tells a great deal about the types of agency and identity that have developed for the transnational immigrant, creating possibilities and limitations that are apparent throughout the activities and daily lives of these individuals. The United States, a leading world super power, shares one of the longest borders in the world with Mexico, a developing country to its south (Ruiz-Beltran & Kamau, 2001). Both countries share a history of ceded territories, political unrest, strong economic bonds and a certain sense of dependency upon one another. Moreover they share a population that transcends boundaries to live transnationally. The stories of these individuals; their experiences; and the challenges posed by new identity formation that they face, as they fall into a new existence, may be ignored by those making bureaucratic decisions that play an integral role in their lives. This may result in dubious existence for the Mexican transnational immigrant and especially the undocumented Mexican immigrant, living and working in the U.S. They may face contested citizenship status, movement restrictions, and other consequences of legal marginality. 25 There exists a logical duality that is the Mexican/U.S. border. As an international border it must separate two boundaries while at the same time be porous and allow for an even flow goods, people and capital (Ruiz-Beltran & Kamau, 2001). Individuals crossing the Mexico/U.S. border are faced with the challenges and confines of physical border restrictions while also being exposed to a border that is circumvented everyday, both legally and illegally with a certain level of ease. Only those migrating from one country to another, for any number of reasons, can fully understand the parameters of the Mexico /U.S. border. This logical duality paves the way for an existence that is at times neither here nor there; encompassing the true meaning of transnational lives. What individuals do, how they do these things and why they do them illuminates how global processes exist and impact lives at the micro-level. Essentially, the historical relationship between Mexico and the U.S. created out of global processes has framed the individual decisions and strategic choices of millions. Throughout U.S. history the government has restricted immigration when they saw fit and opened the country’s borders when it was convenient for it’s economic needs and to ease certain racial tensions (Ngai, 2005). Mexico and the U.S.’s past have created a situational environment prime for living transnational lives. The current physical territory that encompasses the nation state of Mexico and the area we know as the United States have always been linked in some way. Rodolfo Acuña, in Occupied America (2007) characterizes the established relationship between these two neighbors as a “Legacy of Hate” and begins by describing the U.S. invasions of Mexico in the mid1830s and 1840s, The United States, a colonial power long before the Spanish American War of 1898, forged its present borders through expansionist wars…North Americans 26 took land through violence…North American troops committed atrocities that indeed left a legacy of hate. The Treaty of Guadalupe Hidalgo ended the Mexican-American War; however, a pattern for Mexican-North American relations had been established (p.3). However, it was not just the U.S. territorial expansion that impacted Mexico/U.S. relations, Mexicans were drawn to migrate north due to various circumstances and events mitigated by for example: new work opportunities in the U.S. ranching empires in the southwest in the 1850s, displacement due to mechanization in Mexico between 1850 and 1910 and as contract laborers during the first labor shortages of WWI during 1914-1918 (Acuña, 2007). Mexican emigration abounded during the 1920s due to a mismanagement of large landholdings by big proprietors in states like Michoacan, in addition there was a great need for agricultural workers in the sun-belt of the U.S. (Gamio, 1969). As part of a settlement with Mexico over disputes regarding oil extraction in the 1930s, the U.S. and Mexico came to several bi-national agreements. (Potter, 2003). The Mexican Farm Labor Program Agreement, which included the Bracero Program, was enacted to help solve labor shortages during WWII (Garcia y Griego & Campos, 1998). The Bracero Program (1942-1964) provided temporary work visas for Mexicans to work in certain U.S. industries. Recruitment stations were set up in Mexico, where contract laborers were selected to work in U.S. agricultural and railroad industries during one of their times of great labor shortage (Garcia y Griego & Campos, 1998). The agreement forged by the two countries named the U.S. as the official employer, rather than individual growers. It guaranteed labor conditions that the Mexican government deemed appropriate. It also excluded the state of Texas as an employment site, due to previous claims of racial discrimination in that state (Garcia y Griego & Campos, 1998). 27 Still conditions for Mexican workers remained poor in many locations. Critics of the program, have dubbed this program as a type of imported colonialism. Working conditions for those in the program were both hazardous and oppressive: Braceros were not paid according to contractual agreement, often having to work for many hours without pay. In addition, they often endured unsanitary substandard living conditions having no heat, poor water, and unsatisfactory transportation (Acuña, 2007). The program was ultimately terminated after attempts at unionization and continuous complaints about the working conditions and difficulties due to weather of the northwest (Acuña, 2007). Many of the first immigrants from Orango came to Michigan as Braceros in the early 60’s. After the Bracero Program ended, a new type of labor program called the Border Industrialization Program was created in 1965 along the U.S.-Mexico border. The program served as a way to absorb displaced Bracero workers and find them employment along the border region. To do this the Mexican government allowed U.S. investors to open Maquiladoras [factories] and pay Mexicans low wages to produce for the U.S. economy (Ericson, 1970). Many individuals who had already committed a great portion of their lives to laboring in the U.S., due to lack of employment opportunities in Mexico, went to work in the maquiladoras. In essence, they continued contributing to the U.S. economy only now from the Mexican side of the border. While some Braceros returned to Mexico, others chose to remain in the U.S. Acuña 2007 explains that, [those] who had established work and social connections in the United States continued their pattern of circular migration in an atmosphere in which both the authorities and the general public were ready to look the other way as long as the 28 fields continued to be sown with vegetables and cotton, and the lettuce, peaches, grapes, and cherries continued to be picked (p.7). According to Doug Massey temporary guest worker programs, like the Bracero program, create a system that does not halt migration but rather redirects it; after the Bracero progam illegal migration from Mexico into the U.S. soared. Permanent settlement increased, for fear of returning to Mexico with no way to get back into the U.S. (Massey & Liang, 1989). Unfortunately, during this continued migration pattern these immigrants were also stigmatized by the general public in the U.S. as a burden on the state. According to Pierrette Hondegneu-Sotelo’s Gendered Transitions (1994), after the Bracero Program, the high numbers of undocumented immigrants streaming in annually were seen as draining society of various social services (e.g.. medical and educational). To remedy the situation, in 1986 the Immigration Reform and Control Act (IRCA) was established (Massey & Liang, 1989). The act limited illegal entry into the U.S. and criminalized the unlawful employment of individuals without legal documentation. It also granted amnesty to thousands who qualified, namely those who had entered illegally before January 1982, and had remained in the United States continuously without problems (Hondegneu-Sotelo, 1994). The act was intended in order to put a stop to illegal entry, especially from Mexico into the U.S. Many of the first immigrants from Michoacan into Michigan remained in Michigan due to the amnesty granted to them through IRCA Another important policy to recent patterns in U.S.-Mexico transnationalism is NAFTA. In an effort to make the international boundaries of North America less rigid, The North American Free Trade Agreement was adopted in 1993. The agreement reduces trade restrictions and opens up the borders for the U.S., Canada and Mexico to more 29 capital for Mexico, and free movement of commodities for Canada and the U.S. (Rodriguez, 1996, p.225). NAFTA had unintentional effects on illegal migration north. With the introduction of low priced U.S. corn into Mexico, the cost of rural corn production in Mexico was unsustainable, leaving the rural population with nothing to subsist on (Adler-Hellman, 2008, p.18). This shock to Mexico’s agricultural industry occurred at the same time as the peso was radically devalued, leaving masses of unemployed Mexicans with no choice but to venture north in large migratory flows in the 1990’s. Those who stayed in Mexico became increasingly dependant on the remittances sent by children and spouses in the U.S. and essentially served as strong conduits for the transnational migratory process we see today. These individuals and entire transnational communities access their needs through migratory networks across boundaries to those who have the ability and power to secure resources in either location. In The Social Construction of the Mexico-U.S. Border, Nestor Rodriguez (1997) describes such transnational communities as complex entities that change and have increased in size and scope especially since their beginnings, he states that these communities, Contain social structures (economic, family, political, and other institutions) whose reproduction is dependent on this binational relation. While immigrants have always maintained contact with their communities of origin, the present interaction with communities of origin among immigrants in transnational communities has reached an unprecedented level through high-tech communication, jet travel, and superhighways…The constant interaction across the border by transnational residents makes the U.S.-Mexico [physical] boundary seem almost irrelevant. (p.224) Transnationalism suggests a way of life, manner of existence, and migratory process, which tells the story of those living in a place that extends beyond geographical boundaries and embeds itself into the sustained daily existence of migratory 30 communities. Transnational movement is more than just immigrant movement; the contrast stems from transnationalism’s high level of constant interaction and sustained exchange through innovative modes of interaction and activities across borders over extensive periods of time (Portes, Guarnizo & Landolt, 1999). Transnationalism is steeped in the movement of goods, capital, and resources in order to sustain, over time, the livelihood of individuals and or communities on either end of the migratory flow. The key feature according to Castles and Miller (2009) is that for a community to truly be transnational in nature, their transnational activities must be central to their existence. Much research has been conducted on the collective identity of transnational migratory networks and how whole communities are also contributing to an expansive array of organized philanthropic projects in either country of origin or receiving country (Orozco 2000; Portes, Escobar, and Radford, 2007). Philanthropic ventures of transnational individuals and immigrant groups are growing and are important to understanding the scope of U.S.-Mexico relations. The activities of transnational immigrants shed light on the impact and limitations imposed by global processes and federal restrictions on their lives. According to Gonzalez-Baker et.al (1998) Mexican migration into the United States has varied given the economic and political situations on either side of the border throughout the last century. But one thing can be said for certain, over the last several decades, migration to the United States has impacted the Mexican economy and Mexico’s labor supply (Hanson & McIntosh, 2010). Migration has left a lasting impact on both countries and an even more profound impact on those living transnationally. By living transnationally one is constantly in flux, moving from one physical space to 31 another, navigating new systems or structures, communicating over long distances, contributing to life and daily goings on in either country or somewhere in between. This fragmented and yet completely functional form of life poses many challenges and borders for the individuals involved. Living transnationally creates and presents certain dimensions such as borders that must be addressed and circumvented by the individuals involved. In Lynn Stephen’s Transborder Lives (2007) the author presents a unique twist on transnationalism. She argues that the individuals in her study traveling and connected to Oaxaca, California, and Oregon are much more than just “transnational” immigrants, she posits that the term “transborder” is a more adequate reflection of the type of lives these individuals lead. Stating that, They have crossed the boundaries of the nation state as they move between countries. They have negotiated changes in technologies of travel and communication through time…the borders they cross are ethnic, class, cultural, colonial, and state borders within Mexico as well as the U.S.-Mexico border and in different regions of the United States (p.6) Although Stephen’s definition is useful and paints a picture of the many borders individuals must overcome along their journey; this definition pays specific attention to ethnic division and the difficulties faced by indigenous persons coming from Southern Mexico into the U.S. Stephen’s reading of the term “transborder” is rooted in the sense of overcoming multiple borders, especially indigenous ethnic discrimination and negotiating the rights provided and denied by the state to such groups. Transnationalism, a process embedded in Mexico-U.S. relations, routinely creates situations where a variety of borders must be crossed for any number of reasons. There are geographical borders that are crossed. There are linguistic borders, as people learn to 32 speak a foreign language and adapt to new health options. There are social borders as immigrants are ostracized. With regard to undocumented individuals there are legal borders that limit legitimacy as a citizen and restrict certain privileges (e.g. accessing driver’s license); only further complicating life and creating more borders that will have to be overcome throughout the transnational life/process. Transnationalism is a dynamic process that establishes new realities for those living in this particular situation. One of the most important realities that must be addressed in this process is that of citizenship. Citizenship & Identity Created Out of Transnationalism The types of citizenship and identity that develop out of transnational lives play an integral role in the strategic choices individuals make to address their health and that of their family and community. How individuals deal with the consequences presented by these forms of citizenship and identity, serves as a window for understanding global processes in the daily lives of those most affected. As transnational immigrants, in many cases undocumented, these individuals face many challenges in incorporating themselves into the American mainstream. The concept of cultural citizenship addresses the notion of difference in democratic societies (Rosaldo, 1994). Cultural citizenship constitutes a combination of self incorporation into mainstream society, while maintaining the value of different identities and heritages (Flores & Benmayor, 1997; Rosaldo, 1994). Ultimately, to be a cultural citizen one must at once be included and equal, while still recognizing inherent and necessary differences. Undocumented Mexican immigrants have always been on an uneven playing ground: they are both cultural others, and are necessary to the productivity of the U.S. Their ‘culturally depreciated status’ as ‘undocumented’ both marginalizes them and makes them structurally vulnerable to institutions and structures 33 of power, which then frame their decision making process and agency (Quesada, Hart & Bourgois, 2011). Cultural citizenship becomes complicated when the state paints a picture of equality but admonishes and subjugates individuals for not fitting the status quo, leaving the marginalized with aspirations for equality in an environment that imposes scarcity and insecurity. Questions of citizenship are not new, but exploring how new waves of documented and undocumented transnational immigrants deal with matters related to citizenship or why they choose to not fight battles related to their citizenship will yield much insight into the confines and limitations of transnational existence and globalization. Kevin Keogan (2002) argues, in his study on immigrant populations in southern California and New York that, symbolic contexts for how immigrants are accepted or perceived in particular areas of the nation at certain times, allow for the construction of a collective identity as either a problem or an asset to the United States. This argument rings especially true when considering how Mexicans living in the U.S. are represented in popular U.S. discourse. This group, is routinely stigmatized, marginalized, and left to deal with institutions of power by their own accord. Historically academics, prominent eugencists, the media and bureaucrats with their own agendas have systematically portrayed Mexican immigrants, especially the undocumented, in a negative light. Leo Chavez in The Latino Threat (2008) explains that the popular discourse on the security threat Latino immigrants supposedly pose emerged from “a history of ideas, laws, narratives, myths, and knowledge production in social sciences, science, the media and the arts (p.22). Chavez (2008) argues that the undocumented face the most scrutiny because they are deemed a threat to American society, they are targeted 34 for political exclusion, and are subject to laws that prohibit their full incorporation. These individuals face a transnational existence connected to two countries in multiple ways as a means of survival. They are in effect, unacknowledged citizens in two countries that share a historically contentious geographical border. Mark Reisler (2001) explains that most of the dimensions of the contemporary immigrant debate were set in motion during the 1920’s and 30’s. At that time Mexican laborers made up a large majority of the U.S. work force in agriculture, mining, and railroads, yet were commonly deemed a “problem to society”. Emory Bogardus’ Essentials of Americanization (1919), serves as an example of how Mexicans were problematized as ‘individuals in need of fixing’ to be fit into the American way. Bogardus states, An Americanization program for Mexican immigrants includes a wholesale extension of the attitude of helpfulness toward and understanding of them, the establishment of wholesome living conditions for them, and wide adoption of the home teacher method of taking constructive American ideas and standards into their habitations and changing these into places fit for the rearing of American children (p.270) Such discourse aimed at fixing Mexicans in American society is so common that it is normalized in the media and internalized by the immigrant population to the extent that the discourse shapes their behaviors, practices and self conceptions (Quesada, Hart & Bourgois, 2011). These statements serve as examples of structural violence or the “indirect violence built into repressive social orders creating enormous differences between potential and actual human self-realization (Galtung, 1975, p.173). People like Samuel Huntigton argue that “the ultimate criterion of assimilation is the extent to which immigrants identify with the United States as a country, believe in its Creed, espouse its culture, and correspondingly reject loyalty to other countries and their values and cultures” (2004, p. 241). In response to such claims Chavez (2008) asks a timely 35 question: “as people leave one nation and take up life in another, what rights to citizenship follow them?”(p.89). I add to this question by asking, what rights are created and denied through a system of governmentality, that is a system which shapes human behavior through embedded institutional power, changing their trajectory and limiting full functionality as a member of U.S. society. Governmentality Entrenched in Institutions of Power “Governmentality” or the attempt to shape human behavior by premeditated means is a concept introduced in social science by Michel Foucault and others in the 1990s. Governmentality or ‘government rationality’ is taken to mean the governing of mentalities through institutions. The government essentially no longer seeks to administer issues of sovereignty; rather it seeks to control individuals through mechanisms of self governing and self limiting. The concern of the government is the overall well being of a population and its purpose is to secure the “welfare of the population, the improvement of its condition, the increase of its wealth, longevity, health, et cetera” (Foucault, 1991a, p.100). In order to do this, the government rationalizes its behavior through the “conduct of conduct” or tactics and techniques at multiple levels and spaces in order to create a hegemonic response by a population or community. In essence, ‘governmentality’ is “any form of activity aiming to shape, guide or affect the conduct of some person or persons” (Foucault, Burchell, Gordon & Miller, 1991, p.2). In as such, government serves as an activity focused on influencing relations; relations between those entities exerting power and those whom the power is being exerted upon. Examples include “private interpersonal relations involving some form of control or guidance, relations within social institutions and communities” among others (Foucault et al., 1991, p.2). 36 According to Tania Murray Li (2007) the power embedded in ‘governmentality’ operates at a distance, by “educating desires and configuring habits, aspirations and beliefs” (p. 275). ‘Governmentality’ becomes so common place in society that it is hardly recognizable to those who are influenced by its inner workings. With ‘governmentality’ there is not one goal in mind but a series of goals and outcomes that are executed through governmental interventions. By understanding these interventions as interconnected pieces that occur at many stages, one is able to break away from the ideal that government is a single entity, instead there are many parties involved and multiple sources of power that attempt to manage the circumstances under which individuals live their lives (Li, 2007). Governmentality is more than a top down effect, where power is concentrated in the higher echelons of society; instead government rationality asks how multiple agents carry out power and how different spaces are constructed as governable (Dean, 2010) such as the arenas of health care and the border and the laws governing these spaces. According to Foucault (1991), “institutions, procedures, analyses, and reflections serve as the calculations and tactics through which governmental interventions are devised and how the conduct of the population is conducted” (p.102). How these tactics and calculations take form and impact daily lives can be witnessed at multiple levels through various unresolved state, institutional, interpersonal and social interactions and reforms. The implementation of regulations within structures and institutions that are aimed at controlling the actions of people, and the rationalization of such actions, provides a domain for understanding barriers encountered by transnational individuals; for example barriers to health care. Governmentality is embedded in the practices of 37 governmental institutions, for example in those of hospitals, clinics, and insurance programs on either side of the border, creating systems that may be inaccessible to the most vulnerable. As a reformulated twist on the Foucaudian concept of “conduct of conduct,” applied anthropologist Gay Becker applies the concept of governmentality to the U.S. health care system. Becker describes how the government is able to control and oversee the conduct of people through the controlling of resources in the form of lackluster health plans, which only serve as temporary forms of care. The author explains that the marginalized often encounter negative interactions with medical personnel, a confusing health care system and unjust legislation which may discourage them from seeking health care altogether. Such experiences contribute to the “containment” of marginalized populations or inability to achieve and achieve the goals which they desire in the health care system, due to intentional barriers. According to Becker (2004), those at the lower echelons of society (e.g. poor immigrants, undocumented immigrants) are often relegated to piece-meal services or the “safety net” of health care which includes health plans, Medicaid, prescription drug plans, etc. All of which provide some services, none of which are all inclusive. This safety net proves to be helpful on the surface for putting a temporary ‘band-aid’ on immediate problems but lacks the necessary elements to address prevention or support and assist those with life threatening long term illnesses. With all its power, governmentality also has its weaknesses and its limits. If governmentality is made up of multiple layers of power and “power”, as Li describes, is only power when the “target of that power retains the capacity to act” then governmentality also involves the potential for those targets to react to the power relations at play (Li, 2007, p.276). According to Foucault et al. “Power in a society is 38 never a fixed and closed regime, but rather an endless and open strategic game” (1991, p.5). The transnational immigrants I interviewed for this study are ‘playing the game’ and not remaining as stagnant agents. They understand power relations and actions of government and counteract through the use of the very agency governmentality is designed to suppress. In essence, if the power of governmentality is needed to control the conduct of people, than people whose actions are being suppressed have agency and the capacity to formulate a response or potentially react. How marginalized Mexicans on either side of the border navigate assemblages of power, such as institutions of health care, created out of macro-level policy, calls for an understanding of the forces at play in constraining agency and the different forms of agency utilized by these immigrants in order to respond to forms of governmentality. Agency, according to Laura Ahearn is “the socioculturally mediated capacity to act” (2001, p.112). This means that ones decisions to take certain actions are mediated by the society and culture around them. In the case of health seeking, such environments are made up of institutional structures such as hospitals, clinics, health agencies, private practices, etc. which contribute to the social reality of those seeking care. “Institutions tend to have an interest in restricting agency, as part of their overall project to control the thought and actions of the people within them” drawing up certain outcomes for those who do not or are unable to take active roles in challenging or navigating the system in new ways (Buckser, 2009, p. 293). In this dissertation, I will analyze one transnational population’s adaptive strategies, and I will argue that agency is not limited to the individual; instead vulnerable populations, like Mexican immigrants and the 39 undocumented, make use of agency at multiple levels, in order to survive in a system of governmentality that creates barriers to care. Strategic Agency as a Means for Navigating Institutions of Power Here I will utilize the theoretical framework, pertaining to agency, developed out of social cognitive theory, which posits that actions in society are learned through observation in a triadic interaction of cognition, behavior and environment. Albert Bandura extended social cognitive theory to include beliefs in self-efficacy and emergent interactive agency or that agency where people make causal contributions to their future through their motivations and actions on present circumstances (Bandura, 1986; Bandura, 2006). Bandura defines three levels or modes of agency: the personal, proxy and collective levels. Bandura argues that agency at any level is present throughout any society (2006). At times, the individual is in a situation where they must take initiative and make a choice for their health benefit or that of their child. At other times the individual must influence family/friends/outsiders or proxies to act on their behalf, especially when those proxies possess a material or social resource that can be of direct health benefit for the individual. Still there are other instances where the individual and proxies are not sufficiently equipped to handle a particular situation and they must strategize with an extended community or collective body to assist in attending to their health needs. Collective agency involves pooling together knowledge, resources, and skills communally in order to reach a desired outcome (Bandura, 2000). Bandura posits that there are four core properties present in agentic acts: 1.) Intentionality: that is planning, 2.) forethought: that is goals and likely out comes, 3.) self- 40 reactiveness: that is execution of courses of action, and 4.) self-reflectiveness: that is the cognitive response to what one has done (Bandura, 2006, p. 165). Differentiating between the three levels of agency and understanding the four core properties of agency are important in gaining insight as to how these concepts function in complex situations. One should always bear in mind that everyday life requires a combination of all three forms of agency and consistent interrelation between the core properties (Bandura, 2006). I will apply Bandura’s levels/modes of agency to this analysis, in order to document how this marginalized population may navigate barriers to health care. Throughout this dissertation I reference these modes of agency as personal/individual, proxy/family, and collective/community. However, it is important to remember that agency is limited, in that modes of governmentality enmesh themselves so thoroughly into society that individuals do not always understand or control the consequences of their actions. Given the context of each situation and their capacity to react, immigrants attempt to approach how they will navigate the system differently, as either passive or active agents. As such, they either give in willingly to the structures already in place to achieve a desired outcome, build structures for themselves with the networks and resources they have most experience utilizing for their desired outcome or are oblivious to the social forces and government interaction subconsciously molding their existence. However, just as governmentality has its limits so too does agency. If governmentality is limited by the potential for the target of power to react, than agency is limited by the influence of power relations beyond the control of the agent. Take for example gender and age, both factors can have detrimental effects on agentive power. A woman forced by her husband to leave 41 a country and immigrate into another may have no agency and no ability to comply with the four central properties involved in agentive acts. Children in many situations have no agency and have no power to decide whether or not to succumb to the will of their parents or guardians. Essentially, just as people have the potential to react to governmentality they also run the risk of having their actions and intentions suppressed by the imbedded power that exists at all rungs of society. If able and aware of the structural inequities, agents strategize in deciding which level of agency: individual, family and/or collective, will maximize their resources in a globalized world. And which levels will amplify the tools necessary for survival, while traversing physical and institutional borders. Agency theory would indicate that, “sick people seldom respond passively to medical and cultural constructions of their symptoms; in most cases, they try to influence how their illnesses are diagnosed, how they are perceived, and the social consequences that follow from them” (Buckser, 2009, p.294). As cultural citizens individuals strategize to overcome the forms of governmentality which attempt to restrict or limit access to certain resources. For those agents living in rural Mexico and a midsized city in Michigan, the strategies are diverse but palanca [leverage], a form of social capital, found at all three agentic levels, plays an integral part in enabling the individual to circumvent barriers to care. Throughout this dissertation I take the word palanca to mean leverage in social interactions. Such social capital makes use of social relations and connections in order to achieve goals (Lin, 2002). Innovative adaptive decisions implemented for navigating local institutions of health care serve as a window for understanding unresolved institutional reform. 42 The Mexican immigrants interviewed for this dissertation must make strategic choices in order to survive and succeed in systems and environments with limited resources. Surrounded by institutional structures which may be designed to exclude them people must challenge their environment and play a part in devising plans of action and influence. They therefore must adjust their lives to utilize additional agents that can serve as proxies in the acquisition of healthcare resources or form collectives bodies all working for a common goal. The stories in the following chapters serve as illustrations of the adverse situations immigrants face in a new country and how they use various forms of agency to overcome institutionalized barriers to care. 43 Chapter 3: Methodology & Setting, Working Transnationally When I interviewed Fernando and Yadira Segovia for the first time in their small two bedroom apartment in Grovenburg, I sat with them at their newly purchased dinning room table. We were warm inside while the two feet of snow outside made Michigan look like a Winter Wonderland. The apartment was alive with the sights, sounds and scents of both Mexico and the U.S. The smell of chiles that had just been toasted for salsa permeated the air, pictures of Santos[Saints] and a small altar to the Virgen de Guadalupe adorned the walls, their three children argued in English over new Spongebob Squarepants toys, while everyone’s favorite bilingual explorer, Dora, counted “Uno means one and dos means two”. Fernando and Yadira spoke to their children in Spanish and the children responded in a mixture of both languages. I was in the U.S. but I understood, through my surroundings that for Fernando and Yadira their cultural connection to Orango provided a framework for the types of lives they led in the U.S. Why a Transnational Setting? The Mexican immigrant labor force across the U.S. has fast become very valuable to local economies (Zuniga & Hernandez-Leon, 2005). Grovenburg Michigan serves as an example of this trend; the area is home to a growing population of Mexican immigrants who work in all areas of the service sector, most especially: restaurants, dry cleaners, construction and landscaping. Many of those making up this population are recent immigrants to the area. The majority of these recent immigrants have followed the waves of migrants that first arrived to Michigan through the Bracero program and are from towns in eastern Michoacan, most notably Orango. Despite being one of the fastest growing populations in the Grovenburg area, little is known about the lives these individuals lead when faced with institutional and structural barriers to care. In order to understand the structural constraints of unresolved institutional reform the research presented in the following chapters utilized health as a window into the lives of these marginalized individuals. The case of Orango immigrants and their transnational lives in both Mexico and the U.S. serve as an appropriate ethnographic case to answer my central question because 44 this particular population falls into two basic migration trends that are rarely studied in conjunction with each other: the first being the diffusion of settlement of Mexican immigrants to new receiving states or New Hispanic Growth Communities and the second being the high continuous out migration from a traditional sending state in Mexico. There are few studies on established transnational Mexican communities living in mid-sized, Midwestern cities and yet the trend for migration from small Mexican towns into mid-sized cities and rural areas throughout the U.S. is overwhelming. According to Rosenblum and Brick (2011), “one of the most significant trends in the last decade has been the diffusion of Mexican migrants to new destinations beyond these traditional states [California, Texas, New Mexico, Illinois and Arizona]…For example, Mexican immigration accounted for 79% of the total population growth between 2000 and 2009 in Michigan” (Massey, 2010, p.14). In addition, the authors also confirm that, although sending states in Mexico have become more diversified since the 1980’s, the state with the highest percentage (12.6%) of out migration or emigration continues to be the state of Michoacan (Massey, 2010, p.17). Michigan and Michoacan serve as useful research sites to answer my central question of how transnational individuals make sense of and navigate the institution of health care in order to attend to their immediate needs related to survival. The insights, opinions, and observations gained from interaction with this transnational community will be insightful as there is a paucity in data related to the experiences of (undocumented) Mexican immigrants and their family members in Mexico within the domain of health care in new Hispanic growth communities. Field sites. Grovenburg, Michigan is a mid-sized Midwestern city with two hospitals and an employment base that has traditionally been tied to the automobile 45 industry. Grovenburg is located in Istoll County, which offers its uninsured residents, regardless of immigration status, the Istoll County Health Plan. This plan is a form of public health assistance for low income individuals, used to defer the cost of basic health care such as medication, emergency services, and clinical visits. Due to the recent economic downturn and the closing of one automobile plant, Grovenburg recently suffered from high un-employment rates and the closing of various local businesses; yet the city continues to see an increase in the Mexican immigrant population to the area. As a native to the area I have seen these changes to the economy and shift in demographic first hand. My own insight and connection to the people in the area has served as a catalyst for posing questions and understanding the health situation of these individuals. Orango, Michoacan is a small rural town of approximately 1,700 inhabitants. The town is located between Mexico City and Morelia, Michoacan in the central highlands of Mexico. In the past, the town supplied employment opportunities to its inhabitants through work at a furniture factory, a clothing factory or at the local train station. Other inhabitants sustained their families through local agriculture and the processing of timber. Within the last thirty years many of the jobs have disappeared with government constraints on deforestation, movement of factories to larger cities, changes in transportation (i.e. micro-buses instead of trains), and migration trends to urban areas and the U.S. The lack of employment in the local area has resulted in many people following migratory patterns to Grovenburg. Increased dangers in border crossing and the high cost of illegal entry have caused these immigrants to remain in the U.S. for extended and indefinite periods of time. Still, many maintain very active ties to their families and 46 friends in their home town. In order to accurately document the experiences of these individuals, I used the following methods to navigate their transnational relations. Ethnographic Qualitative Research For the purposes of this study I used qualitative ethnographic research methods with a phenomenological lens to study the lives and survival strategies of recent Mexican immigrants and their family members, living in a transnational space. Qualitative research is an inductive process of inquiry based on understanding human conditions through various worldviews (Creswell, Hanson, Plano & Morales, 2007). Such research serves as “a means for exploring and understanding the meaning individuals or groups ascribe to a social or human problem” (Creswell, Hanson, Plano & Morales , 2007, p. 4). Qualitative research or “descriptively oriented research” (Wolcott, 2001), provides intimate levels of depth, narrative, and information from a much smaller sample of respondents, than would be used for a larger statistical or quantitative study. The responses acquired through qualitative ethnographic research cannot be easily categorized, “their analysis rely less on counting and correlating and more on interpretation, summary, and integration” (Weiss, 1995, p.3). I chose to use ethnographic qualitative methods for this study because they provide deeper understanding of how multiple individuals respond in various ways, which may or may not overlap, to particular situations. The ethnographic approach involves studying and observing a small group of individuals in order to gain insight on the perspectives of group members regarding how they organize and make sense of their daily lives. Ethnography calls for on the ground fieldwork that explores a particular human phenomenon. Using ethnographic qualitative methods for this study allowed me 47 to do justice to the variety of experiences and situations that developed by the families who participated in this study over a span of six years. Phenomenological Research The research methodology is also oriented within a phenomenological framework. Phenomenological research involves presenting the lived experiences of individuals through their own perspective, aiming to highlight taken for granted assumptions and ways of understanding particular phenomena that affects their daily lives (O’Reilly, Cunningham & Lester 1999). By examining the health experiences of a group of transnational immigrants and presenting their thoughts, perceptions, and ways of knowing I will gain access to understanding how larger institutional structures have a bearing and meaning on the human lives. The phenomenological approach serves as a powerful tool “for understanding subjective experience, gaining insights into peoples motivations and actions…”(O’Reilly, et al., 1999, p.1). Drawing from the Husserlian tradition Sheree Dukes (1984) explains that there is a double insight inherent to human experiences, first that human experience makes sense to the subject living that experience and second that the logic or meaning behind that experience is created out of the experience itself not by an outside observer trying to make sense of the subjects actions (p.198). This methodology allows for the reflection on ones consciousness to enlighten our understanding of how certain experiences unfold and gather meaning for the subjects living those experiences. Through the use of interviews, participant observation, and conversations participants in this study were able to reflect on their lives while in Mexico, while crossing the border and while living in the U.S. Essentially, voices then emerge from this 48 creation of transnational experience. Although this data does not serve to make broad overarching claims about all new immigrants it does serve to paint a picture for understanding how macro-level structures and policies influence human action and experience and in turn what those health related experiences mean for this particular group of individuals. The Research Sample The study consisted of 32 open ended interviews with a cross section of individuals all over the age of eighteen. The sample consisted of both men and women who have emigrated from Mexico to Grovenburg within the past twenty years and their family members living in Orango, Michoacan (some of whom have lived in Grovenburg). During the course of the study I conducted 18 interviews in Grovenburg. Some interviews took place with additional comments and participation by spouses and in-laws who arrived during the course of the interview. In total, 23 individuals participated and were recorded during the Grovenburg interviews. I conducted 14 interviews in Orango, several of which were with multiple individuals. Some siblings who lived in the same household chose to be interviewed in a group setting and some friends and spouses chose to be interviewed together. In total, 19 individuals participated in the Orango interviews. All interviews were supplemented with multiple informal conversations with additional community members and follow up conversations with those who were interviewed. In total 42 individuals were recorded during the course of this study, sharing their experiences and insight regarding life in and across both locations. Data Collection Process 49 During the course of this study the data was collected through extensive community networking and snowball sampling techniques, participant observation in a migrant hometown association and local immigrant rights advocacy group, semistructured/open ended interviews and extensive field notes taken in both Orango and Grovenburg. In addition, I served as a bilingual community resource for many of the families involved in the study. Specific methods for accessing and working with the population of both documented and undocumented Mexican immigrants in this study are highlighted below. Community networking & snowball sampling. As a Mexican American and native to the Grovenburg area, I have a long history of involvement with the Mexican immigrant community in the city. I also have a close relationship with a large local community of families who have immigrated to Grovenburg from Michoacan, Mexico; a community which continues to draw additional newcomers to this area. More than 800 immigrants now living in Grovenburg come from the single village of Orango, Michoacan. Some of the earliest members of the transnational community to settle in Grovenburg arrived around the same time as my father (in the late 60’s early 70’s) and they grew to know each other through the local church community. Many of the men who participated in this study work, or have worked, in construction; as did my father at the start of this study. I was first put in communication with some of the key informants for this study because their husbands and brothers worked with my father in the 90’s and they would frequent our home. In 2006 I began attending rallies for immigration reform in the Grovenburg area. I was informed as to who organized such events and quickly became involved in a local 50 immigrant’s rights advocacy group3. I began attending meetings and became aware of the political issues at the local level faced by undocumented immigrants; families being divided due to deportations; illegal search and seizures; undocumented children being denied access to higher education; etc. My activity in the group allowed me to get to know some of the undocumented members on a more personal level which later resulted in their participation in my study. I slowly built rapport with members of the community I had not already met, sharing my own thoughts on immigration reform and my own family story of emigration out of Mexico. My involvement in the group lasted one and a half years. In Spring 2008, with the collaboration of a non-profit community organization, I conducted a small exploratory study, which was published in Practicing Anthropology (see Hunt & Montemayor 2010), about Latino health needs and strategies. Data collection took place through focus group sessions and individual interviews at several Hispanic community churches. This study identified unrecognized limitations in available health resources, a host of unmet needs, as well as innovative health care strategies used by Mexican immigrants. Particularly striking were the needs and adaptive strategies of the undocumented participants: using children as translators, paying for out of pocket emergency care at Urgent Care Facilities, and self medicating, to name a few. It was during this study that I remembered previous conversations I had with one undocumented woman from Orango, Michoacan named Alma Marinez, who had been introduced to me through my fathers working relationship with her partner. I remembered how this young undocumented mother of two shared her frustrations regarding issues of language, 3 The name of this group is not of great importance as my involvement waned when the purpose of the organization shifted as it took on a more ecumenical theme, branched out to include other organizations, and members were charged dues. 51 documentation, and lack of formal employment. I was drawn to these themes and how they radically exacerbated the already pressing health needs experienced by many of the American citizens we interviewed in the 2008 study. Struck by the findings from the first study and my conversations with Alma I wanted to know more about the process of gaining access to health resources when one is already in a limited position, as what I like to call an “unacknowledged citizen” or contributing member of a working society, who lacks the formal recognition as such. I contacted Alma Marinez and explained that I was interested in finding out more about the community of Oranguenses that live in Grovenburg and those that have returned to Mexico. She called her sisters in Mexico and before I knew it I had a new host family ready to accept me in their home as I began my fieldwork in Mexico. At that point I personally only knew approximately five families from Orango living in Grovenburg. However, my network of informants in Grovenburg grew significantly after my fieldwork in Orango was completed. In summer 2008, I received a Tinker Foundation Grant to travel to Orango, Michoacan; where I further solidified my relationship with this transnational community. I spent four weeks in the town, building my understanding of the health care system and meeting family members of those living in Grovenburg. In Summer of 2009 I received a travel grant which allowed me to return in October of 2009 for another six week long visit. During that visit, I began discussing health issues with individuals who had a tie to the Grovenburg area and visited the various health care facilities (functioning and nonfunctioning) in the area. 52 I should stop and explain that in order to gain access to this marginalized population, whose members are not usually in a fixed place for an extended period of time, I used network or snowball sampling techniques transnationally to recruit study participants. This method of recruitment allowed me to gain a broad perspective relating to the myriad of health related narratives and experiences faced by a transnational population. This is a community who understands living transnationally because they experience it everyday; friends and family have crossed the border and frequently move information, resources, and kin from one place to another. Key informants, transnational immigrants themselves, who I met through community networking, introduced me to the first layer of study participants. These individuals then put me in contact with additional community members they knew who live in both locations. My time in Orango was essential to gaining access to many of the undocumented immigrants that may not have trusted my efforts before. Isabella Marinez, and Alondra Soto, Alma’s sisters, played an instrumental role in introducing me to several community members who were willing to be interviewed. My criterion for selection was only that the participants be over the age of eighteen and that they have a connection, meaning that they themselves had lived in the United States for a period of time or had an immediate family member who had lived or was currently living in the U.S. (specifically Grovenburg), to the United States. I also wanted a variety in occupations and to have an even sampling of women and men. Unfortunately, the variety in occupations is very limited (mostly farming, construction, and municipal positions) given the socio economic situation in rural Mexico. In most cases the few men still living in the town did not want to participate in the interviews. The men that were interviewed asked that their wives be 53 present. I assumed this was because my presence in their home as a single woman was deemed inappropriate if the woman of the household was not there. At the end of each interview I asked the individual participating if they had additional acquaintances in either location that may want to participate in the study, this created a snowball effect, where one participant led me to interview another and so on. Essentially my key informant in Grovenburg introduced me to new connections in Orango which then led me to an additional set of participants in Grovenburg. The mothers I met in rural Michoacan told me that they would speak to their sons and daughters in Grovenburg so that they could also participate in the study, and as one woman said, “para que puedan compartir sus propias historias” [so that they can share their own stories]. Upon my return from Mexico I extended my network of informants further when one of the Orango community leaders, whom I had met at an immigration rally, and had gotten to know through the immigrant rights group, invited me to become involved with the transnational migrant hometown association, named San Judas. San Judas is an organization that has been formed by immigrants from Orango, living in Grovenburg. My participant observation with this group was especially usefully as I was able to see and be part of an actual transnational organization that functions in order to serve the ongoing needs of dual communities. Participant observation (Migrant hometown association involvement & service as a community resource). The function of Grupo San Judas is two fold 1.) raise funds and help the community in Mexico and the U.S. which includes individual group members on either side in need, especially those with health problems and 2.) to preserve 54 the cultural traditions of their hometown while instilling values in the youth. Orozco (2000) has posited that Home Town Association’s in receiving states fulfill very specific functions such as social exchange of goods and information, political influence, and pursuit of low-scale development, which usually revolves around improving infrastructure, health care and education in sending states. These organizations are groundbreaking in that the philanthropists and transnational volunteers are not second generation economically stable families; instead they are immigrants living on a working wage whose first concern is usually improving their own lives in the U.S. These types of community driven organizations have a long history, impact and influence in and amongst Latin American migrant populations who have lived elsewhere. Portes, Escobar & Radford (2007) identified over ninety philanthropic immigrant organizations within Colombian, Dominican and Mexican transnational communities living in the U.S. The authors described how the groups are formed, the degree to which they impact their countries of origin, the types of immigrants involved in such organizations and why such groups have come into play. They found that, "transnational civic, philanthropic, cultural and political activities are common among immigrants in the U.S. and, on the aggregate, they possess sufficient weight to affect the development prospects of localities and regions and to attract the attention of sending governments" (p. 276). I found Grupo San Judas to be especially interesting as a Hometown Association because they take as their mission the individual health requests of the community members most in need, living both in Orango and Grovenburg. Needs are identified when one of the committee members is contacted and asked to share the specific need with the group at one of their ad hoc meetings. When I first started attending the meetings they 55 took place in the basement of the San Cristobal Catholic Church, immediately after the Immigrant Rights Group meetings. There was a President, a Secretary and Treasurer for the purposes of note taking and accountability, as a registered organization within the parameters of the church. However, all members who were present for any of the organization’s meetings were allowed to share their opinion and their concerns were given equal weight. The meetings were set in place as a discussion forum where suggestions for improving the physical state and appearance of the community’s home parish in Orango and their new parish in the U.S., were discussed. In addition, pleas for assistance in the form of written letters were shared with the group and decisions were made in democratic fashion as to how funds would be raised to help those in health crisis with limited funds and lack of insurance on either side of the border. I joined the group when planning began for a Kermes4 [fundraiser] to raise funds for thirty-seven year old Juanita Carranza. Juanita, was an undocumented single mother, who worked for a dry cleaner and needed radiation treatments for her Uterine Cancer. Her case was presented before the group and all were in favor to proceed with planning and execution of the event. More about Juanita’s case is presented in Chapter 6. Grupo San Judas also takes pride in organizing events and festivities that do not raise funds but do serve to preserve their ethnic heritage, i.e. Stations of the Cross, The Feast of Our Lady of Guadalupe and Posadas during the Christmas season. Although colectas [collections] serve as one means for raising money within the community, the 4 Kermes is literally translated as a carnival. In this case the Kermes serves as a fundraiser with a dance and traditional food. All food and alcohol are donated and prepared by community members from Orango. The food prep team is led by Mercedes Perez or Victor Marinez’s wife Doña Naila. The events are promoted throughout the Grovenburg community and especially at San Cristobal which serves a much larger Hispanic population. A list is kept of those who donate money, alcohol, or food items and recognition is given at follow up meetings. Attendees (including those who made donations) are charged for entrance to the event, once the dance portion begins. Food, spirits and raffle tickets are sold for reasonable prices and children are always welcome. 56 kermes has become the group’s trademark for the fun, food and company. Every few months a kermes takes place procuring funds for an individual in need in either location or to improve one of the churches (San Judas in Orango or San Cristobal in Grovenburg). There was rarely any in-fighting, that I was aware of, and group member responsibilities were fairly cut and dry, one donates when they can, one helps when they can, and one attends meetings when they can. Only recently has the group begun talks with Mexican Government Officials in order to develop new ways to contribute financially to community infrastructure related needs in Orango. Figure 1: Community Gathering [convivio] with powerpoint showing San Judas Church improvements funded by remittances sent from the Hometown Association, Grovenburg, Michigan Figure 2: A posada [Christmas shelter reenactment] in the home of one of the Hometown Association members in Grovenburg, Michigan 57 My participant observation in Grupo San Judas was a very personal experience, where I became as invested in the efforts of the group as any other member. I understood the challenges many of these immigrants faced because I helped them to navigate the intricate web of resources both locally and transnationally. I grew to know many members of the community and they became my extended family. I was invited to be madrina [Godmother] for several Quinceañeras [fifteenth birthday celebrations], presentaciones [3 year old presentations] and Bodas [weddings]. I was known as a tía postiza [or stand in aunt] for many of the children. I accompanied many of the group members to doctor appointments. I translated both medical and educational documents for families. I accompanied children to immigration detention centers where they were able to speak with parents facing deportation. I took “Dreamers” to apply and get finger printed for green cards when their undocumented parents did not want to risk the trip to the Immigration Office. I accompanied minors born in the U.S. to undocumented parents, as they traveled across the border, in order to be reunited with family. I organized a tutoring program for the children of these immigrants and was able to assess first hand the immediate health needs of the mothers as I taught them health related English terminology. Through all of these experiences I was welcomed by the community members and had many rich informal conversations about their health and immigration concerns. 58 Figure 3: Serving as Madrina[Godmother] for a presentación de 3 años[3 year old’s Presentation] My participation in committee meetings, family gatherings and informal conversations were useful in understanding the limits of the health care safety net used by these individuals in Mexico and the U.S. The work performed with Grupo San Judas was used to add breadth to the insights gained from the in person interviews I conducted. Essential to participating in this community and observing the actions of the individuals involved, were my field notes of these observations. During note taking I documented any health-related details, such as recommendations for Spanish speaking services, sources for inexpensive pharmaceuticals, reasons for migration etc. and additional questions that could be included for added insight. Semi-structured/open-ended interviewing. Before beginning the interview process participants gave informed verbal consent to be tape recorded. I chose to use semi-structured open ended interviewing techniques in order to provide an open forum for elaboration and answers that did not require a limited response. I began with an interview schedule that reflected themes from my initial community observations and 59 some of the concerns that presented from the previous study I conducted regarding health needs for Latinos living in the Midwest5. The questions were broad in scope and left room for participants to reflect on their various experiences. When information was unclear or there was an introduction of a theme of great importance I would ask additional clarifying questions. All the while I endeavored to avoid leading questions and interjections of bias from my own experiences, during the interviews, although at times such anthropological faux pas were inevitable. Each interview lasted between one hour and two hours depending on the participant’s contribution. Data Analysis & Write Up Throughout the duration of the study I took ethnographic field notes recording the diverse interactions of individuals in Grovenburg with their family members in Michoacan and vice versa. I documented life events and how lives were impacted by immigration policy and health care policy in both locations. During San Judas meetings I documented how the group organized itself during their efforts to provide health related resources to individuals on both sides of the border. I also took extensive notes during each individual interview I conducted in an effort to highlight stories of experience, points of emphasis and major themes that I could reference later during analysis. Interviews were then transcribed for accuracy. Transcripts were summarized and translated simultaneously. In the next phase of the study I reviewed the summaries and I systematically analyzed my data through content analysis, referencing the interview schedule in order to extrapolate broad recurring themes that I found apparent or absent from the lives of this 5 For a list of questions that served as the framework for most of my interviews please see Appendix 1 60 community. Themes were refined on an on-going basis, as I reviewed each transcript. I then compared and contrasted the information from both research sites and the various subjects interviewed, in order to synthesize arguments. The stories of experience essentially told the story of my dissertation. The struggles of one family in particular stood out and demonstrated the transnational nature of daily life for undocumented families. I use case studies about this family, the Segovia’s, throughout and at the start of each content chapter as a reminder that migration experiences and seeking out health resources are cyclical and interconnected for the individuals living these experiences everyday. By analyzing my observational and interview data I was able to accurately portray the myriad of strategies used both locally and transnationally to address health related needs of this marginalized population. Furthermore, the analysis yields important information regarding a little known population, undocumented immigrants, and their perspectives, opinions, and experiences related to changes in immigration and health care policy. Activist Anthropology As an activist anthropologist my work is deeply rooted in community involvement and action. In the spirit of Boas my anthropological research engages in creative public discourse so as to present and share the research to a broader audience. Louise Lamphere (2004) argues that anthropology has become increasingly concerned with critical contemporary issues. Before WWII activist anthropologists were marginalized when the discipline sought out scientific legitimacy. Although many anthropologists studied remote tribal societies, minorities, the poor and other 61 marginalized groups; it was during the civil rights movements of the 60’s that activist anthropologists gained new wind and became increasingly unafraid to be concerned with new problems brought about as these groups incorporated into larger society. With new problems, inevitably comes new insight. Nancy Scheper Hughes (2009) argues that it is here amidst new issues of public concern that the anthropologist not only offer solutions but must intentionally make the issues public. According to Bennett (1996) activist anthropology is different than applied anthropology because it is volunteeristic in approach and multidisciplinary in nature, drawing upon a myriad experiences concerned with issues important to the society in the present. Working in a transnational community and serving as a volunteer, allowed for a deeper level of insight and an “on the ground” contribution to the immediate needs of the community members. By doing this type of research I am taking an active role as a socially responsible participant observer and making public the struggle of the participants involved, through my own experiences working with them on a daily basis. Many anthropologists argue for social responsibility in anthropology and provide concrete examples, through ethnography, of ways in which anthropologists put the discipline into practice for a purpose, within a particular community, regarding broad issues of public concern (Berreman 1968; Di Chiro 2004; Low & Merry, 2010). Bearing this in mind I made sure that the anthropology was not just mine, instead I present data that speaks and actively engages the public in contemporary issues for the public good. I have not been an objective observer during the course of this study. On the contrary, my involvement and status as a bilingual educated Latina assisted in serving the needs of many of the participants. I was easily able to weave between spaces and serve as 62 an additional community resource. By acknowledging the value of my subjective position, I am able to present an honest empathy to the study that only a biased observer could contribute. My involvement as a bilingual resource also serves to underscore the communal necessity for such pragmatic resources. Limitations One of the main limitations of this study is the fact that policy at the federal, state and local levels are constantly in flux. Individual stories regarding crossing the border were very different given the conditions during the time at which individuals crossed the border. Individual’s access to health resources also changed as polices changed and the family units potentially became separated. Bearing this in mind it is impossible to make broad claims about the migratory experience from Mexico to the U.S. or healthcare policy because there is such variation involved. From the time this project began to when I finished analysis the face of healthcare in the U.S. had changed immensely and comprehensive immigration reform was being discussed in congressional debates. Another limitation was the lack of male respondents. Although the goal was to have an even cross section of both male and female respondents, as explained in a prior section, my status as a single woman limited the amount of participation from men. In addition, many of the men work long hours and were not available for interviews; while their wives work shorter days or stay home to take care of the children. For this study, I received IRB approval to not ask for signed consent of participation, in an effort to protect the anonymity of undocumented participants involved. Even with these precautionary details I believe there were several cases where the individuals did not fully disclose all information regarding their experiences. For the 63 most part there was a substantial level of comfort but it is to be expected that there may be some level of self censoring involved for fear of being caught and deported. In a similar vein many of the immigrants involved in this study moved back and forth between Mexico and the U.S. several times throughout the course of this study, their life situations changed on a daily basis making it challenging to devise a time frame for this study. Instead I chose to present the data based on the location of their experiences before leaving Mexico, while crossing the border, upon arrival to the U.S. and during return visits/stays back in Orango. The experiences of this particular transnational community of immigrants, their interactions in both field sites and struggles while crossing the border are presented in the following chapters. 64 Chapter 4: La Vida en Michoacán, Why People Leave & What They Leave Behind Fernando Segovia left Orango, Michoacan in 1994 at the tender age of 16, with high hopes of getting ahead in life. Although his grandfather had a furniture making business the pay was insufficient for the many family members who were employed at the business. Fernando felt “the situation,” meaning the economic and socio-political environment, made living in rural Mexico almost impossible. “There was no way to survive”. Fernando made the decision to travel to the U.S. as an indocumentado [undocumented immigrant] with several of his cousins and followed his uncles who had already established themselves legally in the Midwest through the Immigration Reform and Control Act in the 80’s. When he first started crossing illegally it seemed a lot easier. The first time, he and his cousins took a bus to Ciudad Bravo, twenty minutes away from Orango, and then caught a bus that took them to the border. It took them two days to arrive at the famous crossing point of Agua Prieta, Sonora. At that time it was not difficult to find a coyote once in Agua Prieta. They simply walked into Tucson and then caught a taxi to Phoenix. From Phoenix, approximately fifty people boarded a large moving truck that took them to Chicago. Fernando then followed the invitation of a family member to go to the smaller city of Grovenburg in Michigan with several of his cousins. Once in Grovenburg the young men liked the city and decided to stay because there were many more opportunities than in Orango. Fernando had dreams and aspirations in coming to the U.S. He and his wife, Yadira, had dated for quite a long time before he decided to leave Mexico. He had always said “someday I will go to the United States and I will be able to build her the home she desires”. Fernando lived in the U.S. working and saving money for those he left behind, his father, mother, siblings and Yadira, the love of his life. After two years of working in the U.S., Fernando returned to his hometown to marry his childhood sweetheart and fulfill the promises he had made. The story of Fernando and Yadira may sound like the story of millions of undocumented Mexicans that leave their native Mexican villages and venture into the United States everyday. However after speaking with this family at length and getting to know them over several years I have learned about variability and how each individual, family, and community act and react in unique and innovative ways to fulfill particular needs related to immigration and health. After hearing about the difficult lives the Segovias led in Mexico, their reasons for leaving and their multiple journeys from Michoacan to Michigan; I have realized that this family, like many others from their 65 native Orango, are not defined by the limitations of macro level institutions, instead they meet these challenges through the use of innovative agentic strategies for survival. In this chapter I will begin to deconstruct contributing factors to the complex global process of migration by contextualizing some of the transnational needs, resources and agentive strategies for survival found among a group of Michoacan residents with ties to Mexican transnational immigrants living in the U.S. I will first examine the conditions that have led to the exodus from Orango and the void that such mobility produces for those left behind, leading them to make strategic health choices when there are institutional barriers to care. The work of this chapter moves beyond neoclassical push-pull models, which define the immigrant as an informed individual agent who is able to clearly weigh economic costs and benefits and chooses to move to a high wage earning country (Ravenstein, 1889; Savitri, 1974; Borjas, 1989). I provide an understanding for why and how this small town in Mexico has become linked to the United States by transnational means at the individual, family/proxy and communal/collective agentic levels. Instead of acting as individual agents in all circumstances I underscore how the face of agency changes in accordance with specific situational needs. I highlight the factors taken into consideration, limitations on where and how people seek care in Mexico, and how needs are best fulfilled through a complex network of resources and knowledge found at all agentive levels. I focus on the situational context of life in Orango, Michoacan for the immigrant as decisions are made to leave and what this does for the situational context of life for those who stay behind. Moreover, I share the stories 66 of several severe health cases that serve as windows for understanding the strategic agency involved for those who remain in Mexico, at these multiple levels. Who is Leaving Michoacan? Figure 4: A panoramic view from the cemetery of Orango, Michoacan According to Elizabeth Fussell and Douglas Massey’s (2004) study regarding sources of Mexican migration streams, men often migrate first from their communities of origin in Mexico and facilitate additional trips in the future encouraging additional family members to join. As the vignette at the start of this chapter reflects, in the 90’s, young men from Orango between the ages of 15 and 20 were enticed by their “legal family members” to try their luck for short periods of time in the Midwest, an area that already had an established history of migration and settlement. Eventually decisions were made by these individuals and their families to stay in the U.S. or return to Mexico based on their sense of community, the possibility of bringing additional family members across the border, how tight border security was at the time and where their children were born. Migration from Orango to Michigan was not motivated solely by individualistic pushpull factors. Portes and Borocz (1989) explain that such labor migration is sustained over 67 time due to the involvement of social networks at the microstructural level and a long defined history of migratory patterns at the macrostructural level. The possibility and choice to migrate from Orango to Michigan is thus motivated by a host of local, national and international factors unique to each individual, family, and the transnational community at large. Gender also plays an important part in migration from Orango to Michigan. By the Mid-90’s the majority of Orango’s male population had migrated north to Michigan. Women also left in the 90’s to join siblings, husbands and other family members who had already established themselves in Michigan. However, the migration of women from Orango to Michigan should not be categorized solely as a type of chain family migration; many of the women chose to leave Orango in an effort to seek better financial opportunities and stable sources of employment autonomously in the U.S. so as to assist in the daily care of family members such as siblings and parents who remained in the town. According to Pierrete Hondegneu Sotelo’s, Gendered Transitions (1994), women’s roles in migration patterns contribute to a shift toward a more egalitarian relationship where independence and autonomy play a significant part in migration related decision making. Several women in this study formed relationships, domestic partnerships and marriages once in the U.S. with men they had known since childhood, yet had never considered dating. Other women started relationships with men who returned home briefly for visits to Orango, would then marry and join their husbands, family and community in Michigan in order to double potential economic growth for their newly formed family and extended families in Orango. 68 Yadira and Fernando Segovia serve as an example of the type of migration where a young male leaves the town following others who had left before him. Then a process of cyclical migration takes place solidifying a transnational relationship between Fernando and both locations. The specific reasons both young males and females left Orango in the 90’s are very much tied to a longer historical relationship between both countries, particular bi-national institutional reforms that spurred migration and local issues with infrastructure and sustainability. Although each individual and family case serves as an example of the variability involved in reasons for migration, specific factors take overlapping roles in many of the cases I came across throughout my fieldwork. Leaving Michoacan: Conditions & Infrastructure at the International & Local Level What are the specific reasons natives of Orango have left their town and ventured to the Midwest? What are the conditions and infrastructure they are leaving? It is no secret that Mexico is a significantly poorer country than the United States, a country with which Mexico shares a 2,000 mile border (Massey, Durand, & Malone, 2003). Declining prices on agricultural goods, harsh living conditions and the influence of free-market neoliberalism during the last 50 years have led large waves of rural Mexicans to venture to Mexican urban cities for work; over population in cities and lack of jobs have forced these migrants and their urban counterparts to cross the border north especially within the last few decades (Adler-Hellman, 2008). Both positive and negative factors/outcomes are involved in the decision to leave one country and go to another. At times the waves of migration from Orango have mimicked larger waves of migration north from all over Mexico that occurred simultaneously with the Bracero Program, economic crises, high unemployment, violent drug wars, and poor 69 infrastructure. Many failed national and international institutional reforms, within the last fifty years, aimed at promoting a neoliberal agenda and limiting the unauthorized entry of international immigrants, serve as contributing factors leading Mexicans to migrate north. In 1982 Mexico suffered a financial crisis which led to a 70% peso devaluation, this period of time marked the end of one financial era and the beginning of labor and production liberalization for the country (Martinez, 2007). Many rural immigrants ventured north illegally during this period of economic liberalization. According to several individuals I interviewed, 1986 served as a year that changed migration from Orango for decades. Since the 1986 Immigration Reform and Control Act, a series of waves of immigration took place within the Orango population leading to a cadena [chain] of migration that has had a clear effect on the current state of life in the municipality. Several of the most well known families of Orango had male heads of households living in Michigan prior to 1986, for example Don Geronimo Carmona, Don Salvador Alvarez, and Victor Marinez left Orango headed for Michigan after the timber industry in Eastern Michoacan was practically eliminated. The three men were granted amnesty through the IRCA and quickly applied for resident status or green cards for their family members living abroad. Given age and marital status restrictions, many of their children 18 and older did not qualify for residency. This left a young adult population in Orango without family heads of household, no stable sources of income and a lack of government intervention in creating new employment opportunities. By the 1990’s basic crop production in Mexico suffered, especially in rural areas due to international and global competition from sweeping neoliberal reforms like NAFTA. At the same time, 70 government involvement in agricultural matters declined, federal subsidies were scarce, and lack of agricultural modernization contributed to an increase in rural migration to the United States, where federal subsidies to agriculture simultaneously increased giving U.S. farmers an advantage (Martinez, 2007). The 1994 NAFTA, a free trade agreement between Canada, the United States was designed to expand capital investment opportunities, ideally creating jobs for the Mexican population (Martinez, 2007). The agreement increased capital mobility, placed heavy restrictions on human mobility, privatized farms and practically eliminated the ejido [communal land] farming system causing a significant portion of the peasant population to seek employment and stay north of the border (Fernandez-Kelly & Massey, 2007, p. 99). Global economic treaties such as NAFTA contributed greatly to the economic instability in rural communities throughout Mexico (Martinez, 2007), such as Orango. The need to support and sustain family members over the long term resulted in a network of migrants who left Orango for brief periods of time to work in Michigan who then returned to their native Mexico. After the attacks on the World Trade Center on 9/11 border security increased and movement within the United States, especially by air, became more restricted. Undocumented Mexicans migrating through the U.S. found it difficult to travel domestically without a state issued license. As a result, Mexican migrants were slowly forced to become Mexican immigrants, during the 90’s and early 2000’s, choosing to stay in the United States permanently or for extended periods of time. In other instances, shrinking employment opportunities in Orango in combination with these large macro-level institutional reforms led individuals, families and almost the entire community to exodus. People have chosen to leave Orango for a whole host of 71 reasons over the years. One thing however can be made certain, both cyclical migration and permanent migration have left a void in Orango impacting those who have left and the community members left behind in both helpful and detrimental ways. According to my Orango interview with 43 year old store owner Rutilio, who had already experienced living in the U.S. for 13 years, In the past, the jobs that were available [in Orango] revolved around the train and the illegal timber industry; the money was good, people would buy their cars and carry their timber back to the towns to sell. But the forests disappeared and everything else disappeared and many people began to run to the United States. Rutilio, like many other working individuals in Orango, has witnessed many of the local changes affecting economic growth. Orango is situated near an important forested area known as the Monarch Butterfly Biosphere Reserve and World Heritage Site. Beginning in the 1980’s, laws were enacted to protect the nearby forested areas from over logging because they serve as the overwintering home to the Monarch butterfly. Heightened enforcement against logging played a central role in eliminating various timber related sources of income for the local population (“Reserva Especial de la Biosfera Mariposa Monarca,” 2007). In 1980 the president of Mexico issued a proclamation in an effort to protect all overwintering areas from all uses that posed detrimental to the reserve (Brower, Castilleja, Peralta, Lopez-Garcia, Bojorquez-Tapia, Diaz, Melgarejo & Missrie, 2002). This proclamation was vague and in 1986 President Miguel de la Madrid issued a decree that protected five of the twelve mountain ranges that serve as part of the reserve (de la Madrid, 1986 as cited in Brower et al., 2002). Unfortunately the needs of the human inhabitants and the biological needs of the reserve were in conflict with each other. Protection efforts were lack luster at best and trees continued to be cut down illegally; by the late 90’s there was serious degradation in the 72 surrounding forest areas (Brower et al., 2002). The collecting/selling of timber and the furniture making/varnishing industry which had served as primary sources of employment for the surrounding population slowly were eliminated at the local level due to deforestation as well as the protection efforts by the government to stop deforestation. In 2000 the President of Mexico Ernesto Zedillo issued a new decree that expanded the protected area of the reserve, ensured compensation for inhabitants of local villages that had given up their wood rights and assisted in changing these areas to conservation based economies (Brower et al., 2002). Unfortunately, these recognized efforts came too late and at too high of a cost, much of the local population in and around Orango had already migrated to the United States because of lack of employment and chain migration. Another hardship in the community came 20 years prior to the start of this study when an important source of transportation and source of local employment, the local railroad connecting nearby towns, closed leaving a large portion of the Orango population unemployed. The cost of maintaining the railroad and the long waits in order to get from one location to another played a large part in the decision to close the railroad down during a time when other forms of local transportation became popularized and more convenient. Railroad workers were granted retirement benefits which include IMSS coverage; but accessing care and services available through this program often proved difficult for rural inhabitants, like those living in Orango. Although government sanctions on the illegal logging industry and the closing of local railroads had negative effects on job availability for the local population these actions also had some positive impacts on the local economy. In order to increase the speed with which people would travel from Orango to neighboring cities like Ciudad 73 Bravo, micro buses and taxis were introduced providing jobs for chauffeurs and increasing the potential for commuter travel when the furniture industry and other factories moved from rural towns to larger nearby cities. Residents of the municipality of Orango no longer had to wait on trains that only passed through the town twice daily and took hours to arrive at their destination. The protection of the Biosphere Reserve has not only assisted in ensuring the longevity of the Monarch Butterfly, but also increases ecotourism to the area and supplies some forms of employment (i.e. hotels, restaurants, tour guides, etc.). These positive impacts on the local economy have proven fruitful for a small percentage of the population. However the few jobs and economic opportunities left in the town are not sufficient to sustain the entire population. As is the case in most rural communities in Mexico the main source of income comes in the form of remittances sent from the U.S. How do Residents fill the Void? A Transnational Relationship of Remittances Although the shift in migration pattern from temporary/cyclical migration to more permanent migration has left many rural towns throughout Mexico abandoned, for those left behind, the relationships with the communities and family members in the U.S. are both solid and necessary (Adler-Hellman, 2008), filling an obvious personal, emotional, economic and material void. Remittances provide stable sources of income for immediate family members of those who emigrate (Rempell, 2005). However, remittances are not only used to provide direct economic benefit, remittance monies also create jobs for the local population. According to several of those I interviewed, the average monthly income in Orango is between 200 and 600 dollars for those with stable employment such as a store owner, 74 teacher, etc. Those who live entirely off of remittances sent from Michigan receive approximately 50 to 400 dollars each month, depending on the work climate for those in the United States. There is a unique function to this transnational relationship serving three purposes: money is used to alleviate immediate family needs in Orango, to construct homes in Orango for those living in the U.S. to return to should they be deported, and to create jobs for those building the homes in Orango. While in Orango I had the pleasure of meeting 35 year old construction worker/farmer Constancio and his wife Erlinda. Both had lived in the U.S. and returned to Orango to start a business. They explained in detail why people send money from the U.S. and how such remittances serve as the financial life blood of the town. The two story home they had just built two years prior with indoor plumbing and green grass between them and the neighboring edifices, stood out against the backdrop of connected homes throughout the town. When I began to ask Constancio about his lovely home he explained the deep connection immigrants have with the U.S. after they have lived en el norte [in the north] for a period of time. Constancio explained that the work that exists in Orango is because of the people who work in the U.S. The seasoned laborer explained that in Orango there are no new employment opportunities. “If people who live in the U.S. want to build a house here, it’s their money, sent to construct homes, which supply the jobs in Orango.” Constancio and Erlinda were quick to share how painful the economic crisis, that happened in the U.S., was for those left behind in Mexico, “In the U.S. people were at least able to survive, the situation was much harder on those living day to day in Mexico.” The only way people survived was because of the money sent from the U.S. According to the couple, “The 75 only wealthy individuals in the town are those who live abroad in the U.S. and visit on special occasions or send money to build homes.” Constancio explained that, In Orango people don’t build houses unless they are rich. Somebody who works in the town will never be able to build a house. The people living in the U.S. send money to build homes. This town practically lives off of the people living in the United States who send money to build their houses, without them there really would be no work. Constancio said that recently he had noticed, that for every ten houses built nine of them are built with money sent from those living in the U.S. These houses are for those living in the U.S. as undocumented immigrants and serve as a “go to” home should they ever be deported back to Mexico. The stability the undocumented find in the U.S. has allowed them to create stability in their hometowns and stability for their future should they and their families ever have to start over in Mexico. The mobility of the Mexican immigrant and their liminal status in the U.S., which could result in deportation at any moment, has left remaining townspeople in Mexico with new but limited form of employment. As Constancio explained, during the last ten years, 9 out of 10 houses were constructed with U.S. earned dollars, providing jobs for a vastly underemployed population during times of economic strength in the U.S. Still, the sporadic construction of houses has not served as a replacement for the depleting agricultural industry; people living in Orango depend heavily upon the remittances, knowledge, resources and materials sent from the United States to fill the employment and economic voids. An important goal of this study is to consider how governmentality in the form of macrostructural policies enmeshed in the globalization process, such as NAFTA and IRCA, have created a transnational environment of bidirectional flows that include health 76 needs, resources and strategies. The departure of residents from Orango into the U.S. has left an emotional and economic void in the town which is mostly filled by those who have left, through transnational interactions that supply information, remittance monies, support and resources related to health. Difficulties in accessing certain resources, the reasons why such things occur, and how people navigate a system of limitations, serve as a window to understanding how forms of governmentality impact health and decision making in daily lives, of those who return to Mexico or are left behind. In order to understand this unique relationship between those living in Orango and their family members living in the U.S. and how these interactions are tied to survival, I share several of the health related situations faced by individuals living in Orango which demonstrate how needs are met through agentive transnational acts at the individual, family and community levels. The Health Situation of Those Who Stay Behind: Case Studies in Strategic Agency In Mexico, rural inhabitants have learned to navigate a network of complex health care systems in order to survive. The Mexican government has developed institutions, such as IMSS, ISSTE, and Seguro Popular for health care, that at times alleviate and at others pacify the epidemics of rural poverty and poor health. However, the family members of those who migrate north are not defined by the limitations imposed upon them by the state; they are simply constrained at times and seek innovative ways to attend to their health care needs. Much like their U.S. counter parts, these rural Mexicans have become Mexican health care geniuses breaking barriers and using creative ingenuity, in order to seek out the care they need. These agents are making use of a complex network 77 of tools and resources that are always connected through the permeability of time and space in order to navigate the Mexican health care system. Over the last 60 years the Mexican health care system has seen great changes at the state and federal levels which have brought into existence a myriad of resources for those most underserved and vulnerable. Many of the participants in this study were still trying to understand and utilize the most recently implemented health programs when I conducted these interviews in Orango. Almost all participants I interviewed in Orango had some form of health coverage, had access to free/low cost health care services offered through the Centro de Salud [Health Center] or paid out of pocket through private care. Strategic agency at the individual level. In order to navigate the health care options available in rural Mexico, the individuals I interviewed in Orango took active roles in seeking out resources for care. Those that stay in Orango develop strategic ways to navigate a somewhat oppressive underdeveloped system of health care. In Orango individual agency, that is the personal influence we have on our own circumstances, takes an active primary role in navigating institutions of health care. Individual’s connections at the local and international level play an important part in developing and executing individual plans for accessing health care. The following case study of a woman living in Orango, Michoacan who suffered from a massive brain tumor illustrates the unique strategies used at the individual level to navigate Mexican health care options. Cristina, a 37 year old married woman and mother of three, sat down to speak with me in a group interview setting at her brother’s home on the outskirts of Orango. Her brother Rutilio, sister Maria-Elena and sister-in-law Gloria were all sitting together 78 on a couch in the living room while the children played in the background. I asked Cristina about her experiences with the health care system in Orango and I found that health care services are not limited to one specific geographical area, sometimes the individual has to travel long distances to get the answers and care they desire. Cristana Mondragon remembered vividly thanking San Judas, the patron Saint of Orango for granting her the chance to live when she was so very close to dying. Cristina pointed to the drainage tube in the back of her head covered by her long black hair. She explained that when she first started experiencing the headaches, she chose to go to a private doctor. In her previous experiences with the local health clinic, el Centro de Salud [The Health Center], Cristina knew she would not be treated and would be referred elsewhere, a process that required time and patience that Cristina did not have given the pain in her head. She explained that, “if one has money in Mexico they go directly to private doctors where they are seen immediately”. The first private doctor she saw gave her a series of pain injections, when the pain did not go away Cristina went to a nearby town to seek the opinion of another private doctor. The doctor prescribed stronger pain medication with the same result and then sent Cristina for tests to determine the cause of the pain in a town named Cuilollo, an hour away. The results came back that Cristina had a benign brain tumor on her brain and she was told that she would also need a permanent drainage tube to remove the fluid. Cristina grew nervous and chose to travel to Mexico City where she sought out the advice of her cousin who is a gynecologist for the IMSS system. The doctor recommended that Cristina seek the opinion of his colleague a neurosurgeon also in Mexico City. The Neurosurgeon said that he could perform the surgery but that Cristina 79 would need 15,0006 pesos to cover the cost, money that Cristina did not have. Cristina left feeling defeated with no hope until she spoke to her cousin again and he offered to put her under his insurance plan. He explained to Cristina that in order to illegally fix her insurance papers and say that they were immediate relatives she would need to pay 2,000 pesos and provide her birth certificate to prove that they were related. With IMSS insurance Cristina didn’t have to pay for the operation and the doctors had all the equipment necessary to do the surgery. She said that, “many people complain about the IMSS insurance and how one is not treated correctly but in my experiences I was taken care of well”. During the interview Cristina’s sister-in-law Gloria chimed in saying that, what helped was that Cristina had palanca [leverage] by having a cousin that worked for the IMSS. He had colleagues and he spoke with them and got Cristina in right away. It is a chain of information and people here. Everyone knows everyone, that’s how you make it. Cristina explained that although the entire situation was very scary she was lucky to have her brother, who drove her to the various cities for consultation. In addition, her sister living in the U.S. would send her money to help pay for the prescription medications and studies that were not covered under IMSS, totaling some 20,000 pesos. Cristina said that she can cancel her IMSS coverage and rely on Seguro Popular but that plan is more limited. Unfortunately, with IMSS, she must travel long distances to be seen by doctors because there are no IMSS clinics in or near Orango. She said, “in Mexico the patient decides where they want to be treated depending on the type of health coverage they have”. Cristina chooses to see private doctors first because it is too far to go to the IMSS clinic in Morelia on a regular basis. She said, “the bus passes are just too expensive”. 6 At the time of these interviews the Mexican peso to U.S. dollar exchange rate was 13.24 to every one U.S. dollar. These rates fluctuate and change daily. 80 Cristina’s case serves as an example of how one individual can uses strategic agency to manage their health problems, picking and choosing which institutions and services will most likely best serve their needs. Cristina sought out several services, opinions, and forms of care at institutions from multiple sectors; in an effort to accommodate her needs. As a Mexican citizen with no insurance, Cristina elected to not seek out initial care at the public health center which mostly serves patients with Seguro Popular. Cristina made this decision based on past experiences of having to wait for care at the public clinic and then be passed on to other public facilities where she waited in long lines. For Cristina, private care was the most comfortable and quickest option. After navigating the private sector and realizing that the cost for care was beyond her means, Cristina chose to seek second opinions and make use of her international financial connection (her sister) and her domestic connection (her cousin with palanca) in order to attend to her health related needs. Each step in seeking care was a process that Cristina had to navigate through connections and previous experiences. During the entire process Cristina was faced with prohibitive costs such as for transportation to and from each town or city, out of pocket prescription medication charges, and not being fully integrated into any of the formal health care networks. She navigated the private system through a process of trial and error; the IMSS through the palanca she held with her cousin and the local public health care option through previous experiences which had skewed her view. Such strategic agency which exists at the individual level is driven by the patient’s active role in determining their health outcome. Many of the interviews I conducted in Orango were with single mothers or women whose husbands had traveled to the U.S., leaving their wives and children to fend 81 for themselves in Mexico. How these women act as individual agents in order to care for their children, navigating various health care options and institutions of power, illustrates one way agency can be reclaimed. In rural Orango the head of household is most commonly the patriarch or male. This individual holds the greatest amount of power in making financial and daily decisions in the interest of his family members. When that male head of household makes the decision to leave to the U.S. in order to send money to his family for their survival, the woman must take on new gender roles making agentive choices in the form of daily decisions that will impact the lives of her children. One woman in particular stood out as a fighter, a woman who challenged the gender norms in Orango and fought for the health care services her son required. Fortyone year old Alondra Soto led me through the town with great pride and determination. When the Presidente Municipal [Municipal President] said he was too busy to speak with me, Alondra walked me back to the office and demanded that I be received by the Presidente himself. I felt safe with Alondra and I realized that her tough exterior, evident in the quick twist and crack of a turkey’s neck in preparation for dinner, was a reflection of what this mother has had to do in Orango while filling the role of both mother and father for her children. It came as no surprise, during my interview with this fire cracker of a woman that she has had to piece together a multitude of resources in order to provide for her son who suffers from Guillain- Barré syndrome. After having lived in the U.S. for a few years, Alondra returned to Orango, for the funeral of her father. She arrived with her infant son Oscar for a short visit with the intention of returning to Grovenburg. During her visit Oscar became ill with a stomach virus and Alondra chose to take him to a public clinic where the pediatrician was unable 82 to diagnose his condition. He stayed in the clinic for two nights and unknowingly contracted Guillain Barré, a syndrome where the body’s immune system mistakenly attacks the nervous system causing muscle swelling, numbness and in some cases paralysis. Alondra, demanded that tests be performed to determine what was ailing her son as he began to loose the feeling in his feet and legs, instead he was simply prescribed more medication by the clinic doctors for the stomach infection and numbness in his extremities. Alondra wanted very badly for Oscar to be admitted to a well known children’s hospital in Morelia but was quickly told that they had no room for her son, (she believed this was because she had no insurance at the time and was in the process of applying for Seguro Popular). Alondra immediately spoke with a cousin she had living in Morelia who was good friends with the head of security at the hospital, before she knew it Alondra received a call from the hospital saying that they did have room for her son. He stayed there for two months and in that time the Guillain Barré reached his airways cutting off his breathing. Oscar was then sent by ambulance to Mexico City for an emergency tracheotomy. He was accompanied en route, to the larger hospital, by the chief of surgery because he had never seen such a delicate or rare case in children. The doctors were able to perform the surgery and Oscar was left with a drainage tube in his trachea for the last nine years in order to help him breathe. During her time providing for her children in Orango, Alondra has had to figure out where to get all of the medical supplies necessary for management of Oscar’s condition. She depends entirely on the remittance money sent from her partner working 83 in the U.S. but she distributes and allocates monies according Oscar’s specific health needs. According to Alondra, Many of the supplies were impossible to find in Mexico at the beginning, I had my partner send me a drainage tube according to the exact specifications, from the U.S. once. But then they stopped selling the drainage tubes to him and told him they could only sell him one if the child was with him. Alondra had to learn quickly where to locate the supplies in Mexico. She found out quickly that many of the items Oscar needed were only available by mail order or in larger cities in Mexico. In order to overcome this barrier Alondra got in communication with the distributors and started ordering everything her son needed on her own and paid the shipping costs to have the items sent from various cities throughout the republic. Chords, ligatures, IV’s were supplied through her newly registered Seguro Popular, the drainage tubes she ordered from Morelia, the aspirators she got in Morelia with the first one being from Mexico. The Nebulizer she bought in Mexico City. Figure 5: Alondra Soto killing, bleeding and depluming a turkey at the wash basin of her home in Orango, Michoacan 84 Alondra’s case illustrates how, through individual agency, one must navigate the system with limited resources, i.e. lack of health coverage. Alondra had nobody to guide her decision making process. She was driven by maternal instinct to protect her son and seek out the best care possible. She used the financial support of her partner to pay for the immediate health services provided for Oscar’s care and used palanca through the social capital her cousin had in Morelia to get her son admitted to the Children’s Hospital. All the while Alondra demanded answers and did not rest until she knew what ailed her son. She was aware of the multiple health options and resources available and also knew that by simply getting her sons foot in the door at the children’s hospital, he would have access to other doctors who might take an interest in his case, which they did. Alondra did not stop navigating the system for resources when Oscar was released from the hospital; on the contrary, she took an active role as sole parent living in Orango in understanding the process for seeking and acquiring certain medical supplies not readily available to the general public. Alondra and Cristina served as primary advocates for their own needs. They each followed the necessary steps in acquiring health care, making use of resources and health options at multiple levels. As women they challenged the status quo searching for resources, demanding results, and seeking out assistance from those with palanca living locally and from family living in the U.S. The previous cases only briefly mention family involvement in the agentive decision making process; the following cases highlight the importance of family presence at the transnational level in navigating limited health care options. 85 Strategic agency at the family level. While conducting various interviews in Orango I became keenly aware of the significance of kin relations and the importance of family in facilitating the navigation of particular institutions of health care. Laura Ahearn (2001) poses the question: “Can agency also be supraindividual---the property, perhaps, of families, faculties, or labor unions?” (p.112). In the case of those living in Orango, close living quarters with extended family makes for an extensive network of support that acts in agentive ways to serve those most in need. In addition, the family members of those living in the U.S. maintain a unique bond with their migrant kin, tied through money, opinions, resources, knowledge and conduits for care. In the next story we see an example of how proxy agency, or agency where others make decisions and choices in the interest of an individual who cannot for themselves, takes shape at the family level. In this example family responsibilities are agentive acts divided according to location, those living in the U.S. and those living in Mexico. Each group acted in different ways specific to their location that ultimately served the health care needs of Doña Lucero, the family matriarch, who was facing fatal disease. One day while speaking with the two brothers, Fernando and Gustavo Segovia, I heard the story of their mother’s battle with Pancreatic Cancer. Sitting outside in front of Fernando’s garage eating carne asada [grilled meat] and drinking a few beers, the brothers demonstrated a quiet resiliency as they spoke about their mother’s condition. They explained that their mother had been diagnosed with Pancreatic Cancer approximately a year prior. Telling the story of his mother’s illness was especially difficult on Fernando who had been deported three years before and saw his mother in good health before he decided to break the ten year bar placed on him by ICE and return 86 to the U.S. illegally. Fernando’s wife Yadira spoke to me in the house while we prepared the food to take out to the grill. She told me that her husband had been drinking a lot and she understood why. She said that Fernando was staying up late and drinking because he was worried about his mother’s health and that when he would see her on skype he felt helpless. Gustavo, also very distraught over the situation, was spending his evenings at his brother’s home after they got out of their construction job. When I asked the brothers to tell me about their mother their eyes filled with tears and they began to explain all that had happened so many miles away in rural Michoacan. Fernando said that the siblings living in the U.S. put their faith in the IMSS because they didn’t know a lot about the Mexican health care system. Their three younger siblings living in Orango agreed that they should take their mother to the IMSS clinic in Ciudad Bravo when her stomach started to hurt. The IMSS clinic believed the pain to be coming from her Gallbladder and wanted to perform a surgery but they told her that she would have to wait two months. Doña Lucero’s sons in the U.S. immediately sent money, approximately 3,000 dollars, in order for their siblings to take their mother to a private doctor in Ciudad Bravo for her surgery. After the surgery the doctor found Pancreatic Cancer. Because the siblings in Mexico did not want to pay a huge sum of money in private care they took their mother back to the IMSS clinic. It was recommended that she begin Chemotherapy treatments, she began the treatments but was then placed on a waiting list for five months to finish the treatments. The siblings in Mexico promptly decided to take their mother to a private doctor in Ciudad Bravo to begin Chemotherapy the cost of the treatment was approximately 18,000 dollars and was paid for entirely by the brothers living in the U.S. 87 According to Yadira every other paycheck her husband received during the last year was wired to Mexico for the care of his mother. The brothers living in the U.S. became the sole financial source for their mother’s battle with Cancer. During the course of Chemotherapy Doña Lucero’s condition deteriorated and she was moved to a better equipped hospital in the capital city of Morelia to finish the treatment. This was challenging for the family because they did not have other relatives in Morelia to stay with and hotel rooms were far too expensive. The siblings in Mexico decided it would be best to take her back to her town after each treatment. To make transportation easier from city to city Fernando sent his family a truck from the U.S. After her treatments, Doña Lucero was sent home to Orango where her health remained stable for a month then worsened. Her children in Mexico decided to take her to a different private doctor in Ciudad Bravo to find out what else could be done. Yadira explained that before they could take her for the consultation they had to send more money from the U.S. because, “In Mexico if you don’t have money in your hand or the deed to your home, they don’t take care of you”. The new Oncologist in Ciudad Romano told the family that the Cancer treatment had been handled wrong. In his opinion she should have been treated with radiation immediately upon diagnoses and then Chemotherapy. Instead she waited several months and this caused the Cancer to grow much faster. In the end he still presented the family with the option of radiation but Yadira said that “by that point it was just to suck more money out of the family”. Doña Lucero endured two Radiation treatments and her sons sent over $7,500 dollars for each treatment. Yadira said that the most challenging part for her husband was that he had to blindly put his faith in two systems he knew nothing 88 about (private care and IMSS) and allow his younger siblings to make major decisions about his mother’s health. Fifteen days after her last radiation treatment Doña Lucero died in her home. By that time she had lost all sight, the ability to speak, no longer ate and according to Fernando’s sister there were tumors all over her body. Doña Lucero continued to ask for treatment and begged her children in the U.S. to not let her die like the people who were dying in the IMSS clinic. Doña Lucero never knew she had Cancer, the siblings in Mexico decided that such news would scare her to death. In the case of the management and care of Doña Lucero’s condition, some of her children were in charge of making health related decisions because they lived in Orango and were familiar with the various health care options available. The other half of her children, those living in Michigan, were left with the responsibility of funding her health care and facilitating her transportation to and from appointments, by way of sending additional resources, i.e. money and a truck. Doña Lucero was not an active agent in facilitating her health outcome given her age and condition. Proxy agency in the form of family decision making on both sides of the border played an important part in attending to the needs of this woman. Doña Lucero’s children were charged with the responsibility and actively used their agency as family members to determine the necessary types of care to aide their mother. As is often the case in migratory situations involving kin, gender must be taken into consideration and gender roles must be put in dialogue with one another (Hondegneu-Sotelo, 2003). For example, one of Doña Lucero’s daughters was left with the role of care giver, a role that is often expected of the stay at home daughter. Her position became much more complex when she was left to make all health related decisions regarding how, when and 89 where to seek her mother’s care. Her two brothers were charged with the responsibility of providing financial resources and sought out other resources that might assist in easing the burden of care for their mother. Because they were unaware of the changes in the Mexican health care system and what exactly was available for use, they had to trust the information that had been given to their younger sister and believe that the health care providers had their mother’s best interest in mind. Doña Lucero’s care givers and financial providers served as the gateway between this woman and a complex system of institutions and transnational information. Given the limited availability of IMSS clinics in Mexico, when one arrives at a facility that is attending to the needs of people from an entire region it is common to wait in long lines for appointments, services, and diagnoses. Unfortunately in this case Doña Lucero was also initially misdiagnosed and was told that she needed surgery on her gallbladder which delayed treatment at the IMSS clinic and sent the family to seek care in the private sector; a solution which incurred high costs for the family on both sides of the border. In many developing countries both economic and medical resources are not readily available to the entire population, in other instances such resources are available at the national level but services may be limited at the local level or in rural communities (Ugalde, 1985). Given my own experiences getting to know the available resources for medical attention in Orango, I found that on the surface, many options look available, however prohibitive costs or requirements deflect people from seeking care. In managing health care, given the limited resources available in a small town like Orango, rural inhabitants may become strongly tied to their family members living across the border in order to acquire the goods and services needed to survive. In one case, I found myself 90 directly drawn into the procurement of health related material culture for the benefit of one of the women who hosted me during one of my visits to Orango. I became part of the chain or link connecting resources in the U.S. to those needing them in Mexico. Before leaving for the field, I was often stopped by people in Grovenburg and asked if I could fit algo pequeño [something small] in my suitcase for a family member living in Orango. With limited luggage I always found these requests difficult to accommodate and yet I felt obligated to do the favor taking envelops with money, photos, food items, jewelry, baby clothing and other items in my luggage for safe delivery upon my arrival. Before my first trip to Orango, I was asked by Alma Marinez to take a machine to her sister, 49 year old Isabella Marinez, a former furniture painter. I wondered what kind of machine and she explained that her sister had high blood pressure and Diabetes, and so needed a blood pressure monitor and a glucometer. She also suffered from osteoporosis and so needed calcium pills. According to Alma, her sister had to walk everyday to the Centro de Salud and wait in line to get her blood pressure checked. In addition, she had to pay a fee of approximately seven pesos each time she had her blood pressure checked. Alma explained that it was very important for her sister to get her blood pressure checked regularly so that she knew whether or not to take her medication. Alma explained that her sister was at risk of illness if she took the medicine when it was not needed or if she did not take the medicine and her blood pressure got too high. Alma explained to me that the machines and supplements could be found in Mexico but that the quality would not be as good and her sister would have to travel a long distance, several towns away, to see if they were available for purchase. Alma made an individual choice to assist her sister and 91 save her unnecessary trips to the Centro de Salud. Alma served as a proxy agent making decisions in order to provide her sister with an optimal health outcome. She sought out the resources and solicited my help to get the items from the U.S. and into her sister’s hands. My trip across the border with the blood pressure monitor, soy calcium pills and a glucometer was fraught with many challenges. During the two aduana [customs] checkpoints and various security screenings I was asked multiple questions regarding the contents of my bag. I explained the function of the machines and the reason I was taking soy calcium pills with me to Mexico. Alma’s sister, Isabella was allergic to lactose so she could only take soy pills as her calcium supplements for her osteoporosis. I realized quickly that getting medication and health related machines out of the U.S and into Mexico was much more difficult than I had anticipated. As a novice “conduit for care” I had placed the items in my carry on luggage and had to remove the contents several times and explain their origin, destination and purpose. Each of the boxes were opened and the contents and parts of the machines were examined thoroughly by the agents. I was given many dubious looks and at one point I believed that the blood pressure monitor was not going to make it to Orango when an agent dumped out the parts quite harshly onto a conveyer belt and then stuffed the parts back into the box after examination. Once I arrived in Orango I showed Isabella the items. I assisted her in connecting the parts and reading the directions for usage. We checked her blood pressure and she smiled, relieved that her many trips to the Centro de Salud were now going to be less. According to Isabella simply have the machine in her home took a great weight off of her shoulders, removing one of the many stressors from her busy life. Isabella explained that 92 she is often under a great amount of stress because she takes care of the four young children of her two younger sisters. She suffers from clinically diagnosed, diabetes; high blood pressure; anxiety; osteoporosis and vertigo. At the time of the interview she was going through menopause and felt depressed. Sometimes when there is no money or a family problem or somebody is sick or simply if the person you are living with has a problem and you can’t help them find a solution. Sometimes because the kids fight and I don’t know what to do, that can provoke the stress or the nerves. Sometimes simply thinking about what you are going to do tomorrow. Isabella explained that the items sent from the U.S. would be very useful to her given her recent diagnoses of high blood pressure and nervios alterados [heightened nerves /anxiety]. The nerves can be heightened on their own or with the simplest of problems. She said that there really wasn’t a reason why she would get stressed, that it wasn’t one problem that caused the vertigo or the insomnia it was everything together. “All the stress, my illnesses and the menopause, that’s what the doctors have told me.” Isabella couldn’t stress enough how her sister Alma and brother Victor have helped her financially and have taken care of her health needs in the form of sending vitamins, supplements and machines that would be too expensive for purchase in Orango. Isabella shared that she had spoken at length to both her sister and brother living in the U.S. about the difficulty in accessing the necessary medicines. She said that, because she did not have a job anymore she depended entirely on the money sent by her siblings and most of that money was applied toward the purchase of health related trips to the doctor or to purchase medicines. She explained that she was told by her doctor that it was very important to take the calcium supplements, so she traveled to nearby Ciudad Bravo where the cost to purchase such supplements was far beyond her means. She told 93 me about the stress involved in trying to get a hold of what the doctors prescribed, how the trips to the centro de salud were cost prohibitive and how the town pharmacy did not have the medication she needed. Isabella like many others explained that the ideas and structures for improving health care are in place but that the money to provide the resources necessary to bring these ideas and practices into existence is not available. After speaking with the clinic doctor and local pharmacist, I doubted what Isabella and others had shared about limited health resource availability in the town. I was told by these medical professionals that the municipality had many useful opportunities for individuals to access health care and that because of ignorance or stubbornness they chose to overuse the private sector or get things sent from the U.S. Further investigation into the local health structure and available resources, revealed several truths. Alondra Soto and a taxi driver, for the municipality, accompanied me into the mountain ranchos belonging to the municipality of Orango in order to see how extensive the health care resources were in the whole municipality. In each village I found practically brand new buildings called casas de salud [houses for health] sitting abandoned. According to the taxista [taxi driver] small buildings were erected when the centro de salud was built several years before, during a local political administration, that invested money into creating additional avenues for health care to serve those most vulnerable. Unfortunately the administration did not take into account the costs needed to maintain the buildings or the costs of hiring so many health professionals to staff all four casas de salud. As a result, the buildings were left abandoned and are often broken into by local healers in an effort to attend to the needs of those unable to make the journey down the winding mountain terrain into Orango, to wait in line at the Centro de Salud. 94 Figure 6: Abandoned casa de salud (left), Rancho Arroyo Verde, Municipio Orango, Michoacan Figure 7: Note on the door of an abandoned casa de salud in Rancho Arroyo Verde advertising a local curandera [healer] Isabella had also turned to local massage therapists and tried to alleviate some of her health concerns such as the pain from the osteoporosis through alternative means but there came a time for her when these efforts were not enough. The doctors highly encouraged Isabella to take calcium vitamin supplements, however because she is lactose intolerant she needed soy calcium supplements, something practically impossible to get a 95 hold of at any of the local pharmacies. According to Isabella, her only alternative was to turn to her siblings in the U.S. who had explained to her that such items were easy to find and send to Mexico, for a relatively lost cost. Agentive acts at the proxy level, that come in the form of family support and family decision making, seem to be useful in accessing certain health related resources in a health care system that is unable to supply all that they promise. In many of the interviews I conducted in Orango I found that family members living in the U.S. take it upon themselves to make choices and decisions on a regular basis for those trying to navigate an underdeveloped system of health care in Mexico. At times family members on both sides of the border work in tandem to devise strategies that will provide access to resources for a particular family member unable to make those decisions or access those resources on their own. In other instances I found that the family agency strategies grow to include entire communities of individuals all working together in order to fill a void or provide an avenue to accessing health related resources. Strategic agency at the community/transnational level. Transnational migration involves various complex systems and networks that stretch across boundaries introducing new forms of living and serving as catalysts in addressing the needs of the diverse populations that cross them. Transnational organizations such as Home Town Associations often serve as conduits for care and strategic agency at the collective/community level. Decisions are made; plans are devised in order to be executed by the collective body, in the interest of those individuals most in need. Grupo San Judas is a Hometown Association serving the diverse needs of those living in Orango and those living in Grovenburg. The grupo [group] is made up of persons from Orango, 96 Michoacan living in Grovenburg, Michigan. My first interactions with the group were in the form of a comité [committee] meeting, I was invited by the president of the group who I had met through an immigrant rights group. We discussed the future plans of the group and how the community was planning on coming together to do a fundraiser for several children in Mexico. My time working as a volunteer with San Judas proved fruitful in gaining insight as to how direct health needs related to terminal, chronic and fatal disease conditions in Mexico are addressed transnationally by collective means, through the efforts of this Hometown Association. I spoke at length with both the president of the group and the catchall secretary, vice president, treasurer, and administrator of the group, Mercedes Perez. She explained to me how the group functioned as a collective body using social media and an extensive migrant network to share information and pass along the needs of those seeking health assistance in Mexico. People in the group were constantly informed as to what the group was going to do and how their community efforts would serve those in need. The group hosted several kermeses throughout the year to raise money for the church in Orango, the church in Grovenburg, or sick individuals in either location. I sat down with Mercedes one Sunday afternoon in her home in Grovenburg, Michigan and she shared the stories of those members of their sending community in Orango who had benefited from the funds raised by the collective Grupo San Judas. Five years ago Grupo San Judas became well recognized in Orango, Michoacan through word of mouth. People in the town found out that their family members, most of which had moved to the same town in Michigan, had formed a group to maintain their cultural traditions; help individuals living in Grovenburg with their health care needs if 97 they did not have formal insurance; raise money for both church communities in the sending and receiving state; and help raise money to fund the health care of those living in Orango. Conveniently enough and due to the transnationality of the population there are several members who travel back and forth between both locations receiving solicitations for assistance and sharing the requests with the community group in order to organize appropriate fund raising events. Mercedes expressed that now it is very common for families of sick children or adolescents to seek out the president of the organization when he returns to Orango for brief vacation visits in the winter. Another active group member Carlitos, works in construction in Grovenburg and is a legal permanent resident. He travels back to Orango when he is laid off in the winter months and usually takes money raised by the group and delivers it directly to the families seeking assistance in Orango. Since inception San Judas has established a core group of individuals (mainly children and adolescents) that they help. One 18 year old woman’s father contacted Mercedes and expressed that his daughter needed Lupus medication and transportation assistance for frequent doctor visits that were not within their financial capabilities. Another young man of 21 years of age (Mercedes’s cousin) was deported from Grovenburg and upon arrival in Michoacan was diagnosed with kidney disease. His parents contacted the group immediately to notify them of the high cost of dialysis and asked for Grupo San Judas’ help. Another family of an eight year old girl named Carmelita, suffering from Leukemia contacted Carlitos during one of his return visits and made him aware of the severity of Carmelita’s condition and how they could not cover the radiation and Chemotherapy needed to help this young girl. The group was also contacted by a sister of a man whose son also suffers from Leukemia. The 98 sister living in Indiana had heard about the group via the social media site Facebook and solicited the group’s assistance. According to Mercedes, “The group has reserved the kermes during the month of February to raise funds for the sick children and adolescents who are sick in Orango.” Each kermes serves as a community effort where families volunteer to purchase and provide various food items that will be prepared by other community volunteers. The food items are then sold at a dance/fund raiser where all the proceeds are saved and sent to the designated party. Most of those attending the kermes hail from Orango. Mercedes provided me with receipts from money orders and transfers that have been sent to the families of sick children in Orango as well as letters from some of the families thanking Grupo San Judas for their assistance and support. One letter from the family of Gerardo the young man who was deported with kidney failure, gave a cost by cost analysis of dialysis treatments per month. Mercedes explained that unfortunately the group is only able to give the funds from one kermes to the sick children of Orango and each recipient averages only about $300 dollars. Although this amount of money may not seem like a lot, especially when average monthy bills for the treatment of most of these diseases in Mexico fall at around $580 per month, the families have come to depend on these funds within the last three years and the money has helped immensely. Images on the following pages show letters of gratitude sent by the families to the group members. Mercedes shared that in addition to the kermes the group has sporadic colectas [collections] where members are asked to donate funds for sick individuals in Mexico or to help pay for the merienda [snack items] provided at the novenas held for the deceased in Orango. 99 In the case of the terminally ill children living in Orango their parents became connected to a Migrant Hometown Association enacting strategic agency at the community/transnational level to provide much needed health care for their children. In order to build legitimacy for their case they provided letters, photos, facebook posts, and receipts proving the dire need of each child’s situation and their gratitude for the collaboration of the group in attending to their financial requests. In these cases health care is a community effort whereby the young adult and their family members reach out across national borders to seek assistance and the community of immigrants in the United States divides up roles and responsibilities in order to best execute a fund raiser that can provide the most financial resources for each of the identified sick individuals in Orango. Figure 8: Letter thanking Grupo San Judas for their efforts in helping the sick of Orango, Sent from one of the families of a young man on dialysis in Orango, Michoacan 100 Figure 9: A letter sent from a young woman with Lupus living in Orango Michoacan, thanking Grupo San Judas for their assistance. She describes her disease as well as the required treatment regimen. Recently Grupo San Judas has gained the attention of the sending community and one man from Orango is working collaboratively with the group to get them recognized by the Mexican Consulate to garner the group increased influence. With the assistance of this well known local political leader the group is now known as a club de immigrantes under the 3x1 program through the Secretary of Social Development in Mexico. As an official club de inmigrantes Grupo San Judas would be able to provide a certain amount of money that would be matched by the state and the federal government. These funds would be used to assist in the development of infrastructure at the local level on either side of the border as long as it benefits inhabitants of Orango or their family members, such as the building of additional clinical wings on the community health center. Such community efforts extend beyond the local and demonstrate how agency exists at the 101 transnational level in an effort to best meet the needs of those left behind as well as how the Mexican state recognizes this resource, whereas in the U.S. it is not validated. Transnational Strategic Agency: Realities from Michoacan Over the course of the last 20 years the village of Orango has seen many changes related to migration out that have left an economic, emotional and infrastructural void; contributing to the health and well being of those who remain in the town. Individuals who remain are faced with challenging health situations, a variety of health options-all with specific institutionalized rules, and a unique transnational connection to those living in the U.S. In this chapter I have discussed several of the contributing factors leading waves of immigrants from Orango out and into Michigan and I have painted a picture of what this does for the population left behind. Although a void is created by the departure of so many residents it is this very departure that ironically fills the void through a continued relationship that procures information, resources, and money across space and time. Additional studies focusing on the physical and emotional well being of those who remain in the sending state after migration, would serve to better elucidate the impact of migration on families of migrants who remain in the sending state after a majority of the population emigrates out. In the case of residents living in Orango, agency serves an important role in navigating various health care options. Agentic acts at the individual level take many forms, in some cases the individual explores various health sectors and health options in trial and error form in order to alleviate a particular health care need. In order to survive in Orango many individuals referenced their palanca within the Mexican health care hierarchy and their connections with those living in the U.S. as useful navigational tools 102 for survival. At the proxy agency level, those who remain in Orango depend heavily upon transnational relations at the family level to secure health care resources. Family and close friends on both sides of the border work in tandem in the interest of individuals who can’t make decisions or secure resources for themselves. At the collective agentive level those who remain in Orango have found great comfort in the collaborative efforts of San Judas, a Hometown Association. The transnational communications between those in need in Mexico and those able to assist in remedying their health problems in the U.S. is evident in the sustained interactions and letters of gratitude from the prior to the later. Whether at the individual, proxy/family or collective/communal level these agentive acts serve as a snapshot of what people do to solve problems regardless of the limitations placed upon them by macro-level institutional reform. The connections created out of the transnational relationship between those who remain in Orango and those who venture to the U.S. serve in enabling agency to function at all three levels in order to alleviate health care needs. 103 Chapter 5: La Cruzada/The Crossing, Surrendered Strategic Agency in the Land of Liminality Fernando Segovia an undocumented youth from Orango Michoacan had already traveled illegally with cousins north into Michigan. Upon saving sufficient money to buy his girlfriend the house he had promised, Fernando returned to Orango for a short period of time where he reunited with his girlfriend and married her. By 1997 Fernando retuned to the U.S. only this time accompanied by his wife Yadira, both in search of a better future. During that trip the newly married couple traveled from Orango with five cousins. Yadira explained that the trip was fraught with challenges. They found themselves stuck at the border for fifteen days because each time they tried to cross they were caught and deported back to Mexico by immigration. According to ICE procedure each of these short detentions are considered deportations and create a “record” for the undocumented thus limiting future attempts to cross. Yadira said that this happened seven times to the large group until finally they decided to cross in small groups. Once on the U.S. side; those charged with the responsibility of crossing the undocumented made their life a nightmare. During that first joint trip, Fernando was told to lower his pants and his genitals were frisked by unos rateros [some thieves] to see if he had money hidden. The couple explained that if money was found on the person he or she would be beaten for lying. The coyotes [human smugglers] treated them roughly and Fernando and Yadira just followed their instructions, fearing what could happen to them. They finally arrived in Tucson and then boarded a bus to Phoenix and then a plane to Michigan7. Yadira explained that the situation is very difficult for people crossing now. The cost is much higher physically and economically. Yadira said she has heard of women and men getting raped and physically assaulted. At the time of the interview Fernando explained that he had been in the U.S. almost 16 years and he had returned to Mexico twice. He and his wife paid approximately $750 each to cross the first time together by the last time they crossed; the couple paid approximately $3,000 each to cross. Both Fernando and Yadira discussed the high level of risk in crossing and how expensive the journey has become; because of these factors Yadira stated that “even though my mother and family are in Mexico it is not worth the risk of crossing undocumented again. There are many kidnappings and violence.” She now has her family and children in the U.S. and they are the most important thing to her. Yadira explained that the reason they left Orango was because there were no jobs available in Mexico and it is very hard to survive. She stated,“moving back to Mexico would be hard on me and my husband but especially on my three children who were all born in the U.S.” At the time of the interview Fernando said, “it might be nice to return to Mexico to visit”, Yadira said, “perhaps someday in the distant future but we would need to be U.S. residents first.” She said, “If Fernando wants to go he can, but I am staying in the U.S.”. 7 In 1997 one could board a plane without having U.S. identification, since 2001 the standard has changed for individuals traveling throughout the U.S. by air. Now a valid U.S. license, State issued I.D. or passport is necessary and these documents are no longer accessible to the undocumented because they do not have social security numbers. 104 The cruzada is a journey made up of a series of moments in transitional space, where the Mexican, through a rite of passage becomes the immigrant. These moments make geographical borders momentarily permeable for those willing to take the risk and cross into the U.S. illegally. However, crossing the border has become much more of an ordeal given stringent border security re-enforcement in recent years. Since the 1990’s the Mexico/U.S. border has increasingly become blurred with regard to the economic free flow of goods and has at the same time become more clearly defined, physically, through increased border security (Ngai, 2012). Traditional crossing points such as Ciudad Juarez, Chihuahua and Tijuana, Baja California no longer serve as the most viable points of undocumented entry. The Sonoran desert, through Arizona, now sees high levels of undocumented border crossing activity. Since the redirection of migrant flows into the deserts of Arizona/California and the ranchlands of Texas, the annual estimated undocumented death toll along the border is approximately 300; however this could be a serious underestimation as the U.S. and Mexican governments only calculate the number of bodies found (Eschbach, Hagan & Rodriguez, 2003). Although the exact number of dead undocumented immigrants along the border or those who suffer catastrophic illness while crossing will never be known, it can be expected that as more people are pushed to travel through the Sonoran desert, difficult climate and harsh terrain may increase these numbers. In this chapter I provide a brief description of how some failed institutional reforms have exacerbated the costs and difficulties of desert border crossing, creating a dangerous crossing point into the U.S. In order to survive the harsh conditions of the desert border and the challenges of crossing illegally, the undocumented immigrants in 105 this study formed unique adaptive responses such as reorganizing their agentive networks and strategies throughout their journeys, as options and resources changed. As highlighted in Chapter 4, before the immigrant leaves their native Mexico, strategies for survival take form at the individual, family and community level. Crossing the border is the next step for the undocumented immigrant, which they try to negotiate in creative ways in order to reach the U.S. and improve their living situation. Once the immigrants in this study found themselves on the journey across the border many made an agentive choice to surrender their agency to guides and/or the elements, entrenching them further into a state of liminality. Victor Turner’s work (1987) describes such a state as one of ambiguity and transition, where the individual is neither here nor there. By surrendering their ability to be in full control of their journey and situation, the immigrant is in limbo traversing economic, physical, and emotional boundaries and never fully knowing what the final outcome of this journey into the unknown may be until they actually make it across the border. Once in the U.S. a whole new process of liminality begins, that of belonging. The agency described in this chapter is an agency that functions only if surrendered during the cruzada, in order to survive the hostile environment and difficult terrain along the border. Surrendered strategic agency, for the purposes of this study, is an active temporary choice, whereby one gives up their ability to make additional choices to other parties or proxy agents who may have keen insight or power that can assist those most vulnerable. In these cases the immigrants surrendered their agency to coyotes, familiar with the territory and the process of crossing the border illegally, in an effort to survive circumstances that would otherwise be entirely out of their control. 106 Throughout this chapter I illustrate the experience of border crossing through the narratives of those who have lived these crossings time and time again. These accounts serve as reflections of those who have traveled north and have returned to Orango, as well as those who migrated north and have remained in Grovenburg. Emerging from these stories are the multiple costs and difficulties involved in crossing the border which, for many, include poor health outcomes. These stories illustrate how migration is not an individual course of action but a process that is linked to a network of people and places that have taken root due to unresolved immigration reform. A limited network of immediate family, friends, and human smugglers are available to those who make the brinco [jump] across, causing these individuals to adjust their agentive strategies in order to survive. Most individuals who cross must depend on coyotes; individuals who leave people for dead, change plans on a whim, demand money at awkward times and lead the undocumented through the cold desert night. The undocumented do not know what they may face as they cross from Mexico into the U.S. with just the clothes on their back. Each trip across the border is a risk and each risk leads them closer to their dreams or a nightmare. As demonstrated in the opening vignette regarding Fernando and Yadira’s crossing, the undocumented are at the mercy of these guides leading them through the unknown. The undocumented are stripped of augmentative forms of agency, that is, those forms of agency that are easily accessed throughout their daily lives and interactions, as they physically cross the border leaving their support systems behind. The undocumented are alone on their journey except for those closest to them, who are also traveling through unfamiliar ground, and those they pay to cross them safely into the U.S. These 107 immigrants must battle with the elements in unfamiliar territory and navigate the limited options available during their journey in crossing. The only real resource the undocumented have is the coyote and they are entirely at their mercy. The information that is provided to immigrants, venturing north, by the coyotes is often piecemeal, leaving the undocumented in a liminal state, wedged momentarily between a rock and a hard place. A whole network of individuals which include: coyotes, guides, assistants, transport specialists, paying family members on either side of the border, other undocumented immigrants, etc. is involved in the smuggling of undocumented Mexicans across the Mexico/U.S. border. Each individual and his or her cadre are responsible for some part in the delivery of the individuals. One misstep or uninformed link in the chain, that leads the undocumented north, can result in violent outcomes, poor health, being left behind or even death. The case studies in this chapter serve as case studies of the unknown, of a journey that manifests itself differently with every crossing. The majority of the participants in this study have crossed the border many times especially in the 90’s in search of temporary job opportunities that would provide sustenance for their families in Mexico. As also discussed by Leo Chavez (1998), for many undocumented immigrants, crossing the border is not a one time event; for many immigrants the linea [line] is crossed each time an undocumented immigrant is apprehended, deported, returns home to visit/retrieve family or chooses to return to the U.S. Many in this study made multiple trips across the border in the 90’s. This has waned over the years as border enforcement, the risk involved, and the price of crossing have increased. 108 Pushing People to Extremes As border security has increased due to particular political situations so too have the extremes to which people go in order counter such reforms and travel into U.S. illegally. Jason Ackelson (2005) argues that increased threats of national security related to terrorism, drugs, and illegal migration since the terrorist attacks on the Twin Towers in 2011 have led the U.S. government to enact strict sanctions, which have increased border security. In the span of only a few years, border security has increased from minimal efforts in the way of money, personnel, bi-national support and infrastructure to a labor intensive activity demanding increased efforts, support, and attention along the 2,000 mile border (Andreas, 2012). Such strategies to expand, fortify and guard the border have resulted in pushing undocumented immigrants further into the desert as they try to find open pockets of entry. The many costs and risks involved in migrating north serve as indicators of unresolved immigration reform at the federal level in the United States and of a growing international market on illegal human smuggling. For Julio Castañeda, an elected town official and construction worker currently living in Orango, the financial costs involved in crossing the border increased with each trip when coyotes charged more money as border security increased. He explained, “The first time, the trip cost me $1,200, then the second trip $1,500, then $1,800, then $2,000, then $2,200 and now if somebody wants to cross they have to pay above $2,500 and people pay that amount.8” After over ten years of migrating back and forth across the border Julio was caught, deported and a ten year bar was placed on his record prohibiting his re-entry into 8 The interview with Mr. Castañeda was conducted in 2010. The cost of border crossing has significantly increased to anywhere between $3,500-$5,000 per person, given the high levels of border security, influence of drug traffickers in human smuggling, and inflation. 109 the United States. Julio understands that should he endeavor to traverse the U.S/Mexico border he will not only have to pay an exorbitant fee to the coyote but also runs the risk of going to federal prison if he is caught. But not all undocumented immigrants are like Julio. Many will continue to risk their lives in an unfavorable environment in order to get to the United States. Still, tougher border security in the United States and stringent rules on the number of visas issued to those planning to leave Mexico, has not stopped illegal migration (Ngai, 2010). Tighter laws do not address the issue of failed infrastructure in Mexico nor do they take into account the historical migratory connection between the U.S. and Mexico. According to one 55 year old woman named Rosita Carmona living in Grovenburg, My husband was one of the first men to come to Grovenburg as a Bracero in the 50’s from Orango. Soon after, his brother, cousins, and compadres [co-parents] followed. By the 70’s my husband decided to stay in Grovenburg. Each year more and more men came from Orango, at first through the Bracero program, then they were legalized in the 80’s through the amnesty. Grovenburg like many cities throughout the U.S. have a long history of Mexican migrant waves that are very much connected to the changes in immigration laws and border control over the years. According to Freibel & Guriev (2006), stricter sanctions on border controls cause an increase rather than a decrease in illegal migrant flows, due to debt-financed labor contracts that can be enforced only in the illegal sector. Although stricter sanctions may decrease overall immigration, illegal immigration increases and individuals are tied to the high stakes players directing and financing their movement from one country to another. Regardless of attempts to increase border security, fatalities have remained high along the border region, especially in Pima County. The dangers involved in crossing are 110 often felt at every corner as the immigrant must literally stare death in the face and find unique ways to survive. Most undocumented immigrants traveling from Central America or Mexico are unfamiliar with the treacherous terrain and take an average of 3 to 4 days to cross portions of the 200 mile desert, where temperatures can reach 120°F (Whitaker, 2009, p.366). Thirteen of the interviews in Orango made mention of the physical difficulty and challenges involved in crossing the border illegally. My interviews with these individuals were peppered with stories about how the risks in crossing illegally into the U.S. have increased in recent years. For example, 35 year-old construction worker Constancio Basurto, explained that his first few trips into the U.S. were relatively easy but the risk increased during the 13 years he migrated back and forth illegally. Eventually the challenges, difficulty, and risks involved led him to stop making the trips altogether. He reflected on his experiences while speaking with me in his home in Orango, Michoacan, Constancio said that when he first started going to the U.S. crossing was easy. There were no problems, but things have changed, “now people have to walk through the cold desert and there are many ways that people can get sick, or get bitten by a snake.” Constancio recollected one of his last crossings and said, In Agua Prieta there was a tunnel and there were dead dogs, ugly things. During my last trip I even found the head of a person lying on the ground, and a full skeleton. I didn’t know if the head and body were from the same person. And we found a hand that looked like it had been eaten by animals. Constancio was very cognizant of the risks involved in crossing. He highlighted that there are many ways one can fall ill in the desert, die or get dehydrated. Because of institutional reforms which increased border patrolling at common points of entry since the 90’s, such as Operation Hold the Line in El Paso-1993 and Operation Gatekeeper in 111 San Diego-1994, people have been pushed to look for alternative routes. Constancio crossed seven or eight times, he said, “the first four it was very easy to cross into the city but the last few times, they put up the wall and more security.” People now go through the desert and that poses many difficulties. The last time he wanted to cross, Constancio thought twice about it and decided not to go. One has to walk a lot, the routes are tough and you have to sleep in the desert. The people that take you are very irresponsible they drive too fast and don’t pay attention. Many of the coyotes are on drugs. There are many Americans that help people get across and many of them are also on drugs. The atmosphere is very bad. Interviewees often told me of unwittingly hiring bandits and drug traffickers who appeared to be under the influence of drugs while leading them through the desert. Still they needed to hire someone in order to avoid sonar detection, ICE personnel and visible checkpoints that can result in apprehension and deportation. After 13 years of coming and going illegally, Constancio decided that the risks involved in crossing with such individuals would have too much of an impact on his wife and two children. The difficult environment and fact that much of ones fate is left in the hands of careless and violent criminals, only further amplifies the risks involved and how each person must reframe their own notions of agency and choice. Constancio no longer migrates north for work. With the money he earned in the U.S. he was able to build a house for his family and start a stable life in Orango, but the trips across the linea [line] remain as vivid memories for him and for others just like him. The skulls and skeletal remains found by Constancio and others in similar situations remind us that deaths along the border due to exhaustion, dehydration, starvation, and exposure are very real. According to one study between 1990 and 2002 112 there have been more than 3,000 unauthorized citizens found dead or reported missing along the Mexico-U.S. border and over 15,000,000 apprehensions and deportations (Meneses, 2003). From 2012 to 2013 in Pima County, Arizona alone, an area crossed by all the undocumented participants in this study, the number of deceased undocumented border crossers rose from 125 to 146 according to the county medical examiner on September 11, 2013 (Cordova, 2013). Luis Alberto Urrea (2004) argues that neoliberal policies such as the construction of walls and fences at traditional crossing points have pushed undocumented immigrants to cross the border in areas with less visible security, leading them further into the Sonoran desert. This harsh terrain increases the dangers and health related risks for people traveling through the desert. And so I ask how did these immigrants, who have made it to Grovenburg, navigate border crossing with limited resources to avoid death? Shifting Agentive Strategies in Order to not be Left Behind Although it may seem as though all agentive strategies are made on one side of the border or the other, throughout my interviews with those who have made it to Grovenburg, I was surprised to find that many individuals were driven to make multiple agentive choices while crossing. At times these choices were made for and by themselves, for and with those in proximity to them or for children, in an effort to survive. As in most cases, individual agency serves as an important first step as immigrants choose who will guide them across the border and how they will make the trip across. However these plans are often conditional and shift as new players or agents are introduced to the process of border crossing. Many of the cases presented, illustrate 113 how the individuals in this study strategized first by surrendering their agency to the coyote smuggling them across. While the desert itself presents many dangers, traveling through this landscape with human smugglers also presents dangers that the immigrant must learn to navigate. According to Kaiser (2001) human smuggling9 occurs on a global scale and has become such an effective industry it can function as well as a legal corporation; as long as there is a human need to get away from war, poverty, and violence individuals will traverse a myriad of boundaries in order to escape such conditions. And in response there will always be a system of human smugglers willing to aid in these efforts, thus presenting an issue of global concern and increased health related vulnerability for those making the undocumented trip. Smugglers will often begin journeys that lack preparation or they may choose to abandon the negotiation altogether, leaving the undocumented to adjust their agentive strategies in order to make it across. Surrendering ones agency to a seasoned coyote usually proves useful for the novice border crosser, especially as open areas along the border may shift with new policy and the desert becomes the main avenue for entry. After one surrenders their agency over to the coyote, they are at their mercy. The changing interests of the coyote and his network may create additional challenges the immigrant must face, causing them to reassess their ideas of who is in control and perhaps take a leadership role in making decisions pertinent to their future. One example of how agentive strategies must shift and change as resources come and go throughout the cruzada came from my interview with Victor Marinez, the President of San Judas. Fifty-three year old Victor, a construction worker and current 9 People Smuggling as described by the U.S. Department of State is, “the facilitation, transportation or illegal entry of a person(s) across an international border, in violation of one or more countries laws, either clandestinely or through deception, such as the us of fraudulent documents” (www.state.gov) 114 U.S. citizen, reflected on his difficult journey in the early 80’s as we sat on the sofa in his Grovenburg home. He explained how even though he crossed during a time when it wasn’t nearly as difficult as it is now, the stakes were still high. He risked his life and danced with the possibility of death as he made an individual agentive decision to put his fate in the hands of the coyote that led him across the border. Victor said of his brave choice to cross the border, “it’s one thing to talk about it and another to actually do it.” Once he arrived at the crossing point of Ciudad Juarez, he was directed by the coyote to wait for further directions. He and the rest of those trying to cross were placed in groups and directed to wait until nightfall to keep from getting caught. Victor explained that in Ciudad Juarez there were over 200 individuals waiting to cross into El Paso, Texas. As it grew dark the coyotes told the group it was time to go. And so Victor walked into the darkness, not knowing where the coyote was guiding him. Eventually the large group was divided into smaller groups of about 18 people in each, all led by different coyotes. Helicopters flew over head as Victor and the others hid for moments, hoping the lights would not detect their movement in the desert. After walking a long distance the group reached a ten foot fence which they were told to climb over. One person was quite heavy, so Victor and other group members chose to help him and had to pull his body in order to get him over. When they finally got over the fence, those at the front of the group had left the last few members behind. At that point Victor had no coyote. His only guide was the flickering lantern carried by another paisano [fellow countryman] and the boot prints of the group members that went before them. Victor signaled to the others in his group to jump in a hole following the trail of the others and promptly realized it was a drainage pipe. They hung onto each 115 other by their belts so as to not get lost, hurt, or drown. According to Victor, “crawling and being bent over for such a long time was very hard on the body. It was difficult to breath with so many people in such a cramped space.” He felt like his air was running out. The stragglers continued through the damp darkness, following the few noises they heard until they eventually caught up with the other people from their group and their guide. When they finally emerged from the pipes there was a car waiting to pick them up and take them to L.A. Victor said the scariest thing was when he was in the pipe and didn’t know when the water would flow through the pipes and possibly drown him or those he gripped onto. He remembered saying that if he made it through the ordeal he would get a job, stay in the U.S. for two years, go back to Mexico, buy a car, and start a business. Victor made his way to Michigan, where he found a job and was granted residency through the Immigration Reform and Control Act. Victor’s story stands as a testament to the brutal conditions the undocumented have faced and continue to face as they are pushed further and further into the desert. Victor took a risk surrendering his agency to a coyote who left him in a situation with limited survival options. In this case Victor felt compassion to act on behalf of a fellow immigrant and literally pull him across the border by making this choice to help a paisa [fellow countryman] Victor’s own proxy agent, the coyote, left him behind. Victor’s agency had to be reorganized; meaning he first had to surrender his agency to the coyote in order to survive and begin his trip through a space that was unknown to him, he then had to reclaim his agency when he was left abandoned, offering support to those closest to him and making decisions in the interest of the group of stragglers. 116 Victor was fortunate enough to have been in the company of others who quickly found it necessary to support one another in order to survive the situation and elements that were against them. Each straggler had to reclaim their agency and redefine who would get to make decisions for their survival. Essentially what this group of individuals chose to do as a small collective body, reflects communal agency for the common interest of the whole group. The stragglers who were left behind with Victor, who previously did not know each other, supported one another through the temporary experience of being lost and abandoned in unknown territory together. As we saw in the case of Victor individuals can easily be left behind as coyotes press on in an effort to evade border security, with or without those who struggle to keep up with the pace of the cruzada. In order to survive in such situations the immigrant must make on the spot decisions in their own interest and the interest of those closest to them during the journey. As security measures and border enforcement increase, the potential for coyotes to take precautions to remain undetected could result in thousands of undocumented immigrants being left behind to potentially die in the desert. The majority of undocumented immigrants cross into the U.S. with the assistance of a guide or coyote, who most often requires payment for their services. Often, individuals find themselves tied up in a web of financial negotiations, where their safe arrival or that of their children from one location to another is what is at stake. Take for example the case of Susana Chavez, her husband Leonel and newborn baby girl. Theirs is a story of unexpected outcomes. The Chavez’s were unprepared for the change of events that took place during their trip. Susana, a 28 year old dry cleaning attendant from Orango, sat in her home in Grovenburg and told me of her cruzada. Susana came to the 117 U.S. with her husband eight years prior to our interview because jobs were scarce in Mexico, however her journey into the U.S. was not what she expected. When the coyote made new demands Leonel had to reclaim his agency and act quickly as a proxy agent in the interest of his wife and daughter. Susana’s husband had returned to Orango to get his wife and child. He made arrangements with a coyote for the three of them to take a bus from Morelia to the border, then a van across the border and finally a plane from Phoenix to Chicago. However, the trip was not as anticipated. She was told that she would not need to walk, but half way across the desert their group of 20 was divided. Some were told they would board a plane and others were told they would have to walk the rest of the way, through the desert. Susana and her husband had no idea the coyote was going to change the plan and charge an additional fee to be crossed by plane. Susana’s husband begged to pay so that his wife and baby would not have to endure the desert heat. He gave the coyote all the money they had. Susana explained that most of the people who traveled with them did not have money to pay for the plane. What broke Susana’s heart was that before the group got divided they met a woman who was fleeing Mexico, with her child, to escape an abusive relationship. Sadly, the woman did not have money so she had to go with the group of walkers. When the two groups were reunited later on, the woman and child were no where to be found. The coyote said the woman hurt her leg jumping over a fence so they left her and the child behind. Susana’s voice became very somber at this point in the interview and she looked at me and said, “That was the saddest thing…the lady who was left in the desert with her child.” Given the circumstances she assumed that the woman and child most likely died 118 in the desert. Of the 20 people in the initial group only half made it across. Susana never dreamt she would have to face such a dismal reality; that only those with financial capital and a well conditioned physique would survive the brincada [jump]. Susana like many young immigrants are blind to the intricacies and corruption involved in the brincada. They enter the process naively confident, and their eyes are opened only when the shock of death and abandonment stare them in the face. Susana’s survival and that of her daughter depended greatly upon the actions of proxy agents, people they put their faith in to get them across. When the coyote’s plan for the Chavez’s safe delivery into the U.S. changed, Susana’s husband had to reclaim his individual agency in order to act as a proxy for those closest to him with no agentive power. He chose to use his financial power in negotiations with the coyote to achieve the necessary resources for his family’s survival. Leonel did what he had to do in order to avoid the situation the other immigrants with no financial capital inevitably had to face. The border, as we can see, has become the sight of a complex criminal network, where high costs charged at various stages of the migratory journey play an important role in an individual’s outcome. The case of Susana and her family serves to shed light on how economic resources can serve as powerful survival tools even during the actual physical journey of crossing the border. In some instances additional resources such as emotional support at the collective level develop and also serve a necessary purpose for survival along the arduous trek. In one interview with 25 year old line cook Jesus Granada, who now lives in Grovenburg, I understood how although individual immigrants may choose to surrender their agency over to coyotes, they also rely on other forms of agency, that develop out of 119 new bonds created through the journey, in order to survive. Often times, the individuals crossing together are strangers and yet as a survival strategy these small enclaves bond when faced with similar circumstances, offering a support network made up of shared goals, interests, and experiences that simulates the family or collective types of agency they leave behind in their hometown. During Jesus’s description of his crossing I couldn’t help but recognize the contradictory nature of his comments. He said that crossing wasn’t so dangerous and yet he described how the harsh conditions left him with health complications upon his arrival to the U.S. In order to survive the harsh conditions Jesus, along with his fellow paisas, strategized as a collective unit. Jesus Granada left Orango in 1995 because life in Mexico was extremely difficult. He explained that, “back then crossing wasn’t so dangerous.” Jesus left Orango with two friends and they supported each other physically and emotionally throughout the trip. They left Orango headed for Agua Prieta, Sonora, a famous desert crossing point. According to Jesus the desert is the only open place to cross where coyotes can pass the undocumented illegally. Jesus explained, Walking is the best way to cross over. It was very important to help the other people in the group. We all wanted to make it across, through the desert. So we would hold each other’s hand and just kept walking even if we were tired. According to Jesus, the group members had plenty of water to drink but they mostly survived on a diet of potato chips and crackers that they shared. They walked during the hot day and cold night. Regardless of how exhausted they were, they had to push through the journey together. Once they arrived in Phoenix they didn’t have to walk anymore. The group then took a flight from Phoenix to Michigan. Immediately upon his arrival to Grovenburg Jesus was in severe pain and was taken to a hospital by family 120 members in order to have surgery on a hernia. He believes the hernia developed due to overexertion during his arduous walk through the desert because before the crossing his health was fine. Jesus, like Victor and Susana, placed his trust and faith in a system that functions when one surrenders over their ability to make decisions at the individual level. However at times one must adjust and reorganize their agentive strategies when faced with new challenges not anticipated before the journey began. In this case, water, chips and snacks were shared among all the men in the group. The men held hands through the desert in an effort to take care of one another and not lose the weakest travelers to the elements. Although Jesus had to face a difficult health situation once he arrived in the U.S., as a result of the physical strain involved in crossing the border, he was able to survive the difficulties involved in physically crossing the border because of the support he shared with others that were crossing with him. As noted in Jesus’ story, “peoples conjoint belief in their collective capability to achieve given attainments is a key ingredient of collective agency” (Bandura, 2006, p. 165). In order to survive Jesus and the others with him believed that their best chances of survival were as a small collective unit, sharing, supporting and looking out for one another. In order to survive, both Victor, Susana’s husband and Jesus had to strategize liminality in the only way available to them, they had use strategic surrendered agency, putting both their faith and bodies in the hands of the coyotes during their journey through the unknown. Unbeknownst to them their situations changed during the course of crossing and in order to survive they either had to become proxy agents acting on the behalf of those most vulnerable or as a collective body in conjunction with others facing 121 a similar situation. The three examples provided demonstrate how, “individuals are producers as well as products of their life circumstances, they are partial authors of the past conditions that developed them, as well as the future courses their lives take” (Bandura, 2006, p. 165). Each individual strategized as to how their agency would function to create the outcome they desired for themselves and or those closest to them during the journey. None of these individuals anticipated having to reclaim or readjust their agency after they solicited the assistance of a coyote, however the quick thinking and strategizing that employed by these immigrants serves as a testament that the undocumented are anything but passive agents in constructing their futures and surviving. Leading a group of other undocumented immigrants through the desert, making financial negotiations with corrupt human smugglers and banding together with a group of strangers in a similar predicament are but a few of the unique strategies the undocumented enlist in order to not be left behind by the coyotes smuggling them across the Sonoran. For others agency must be surrendered and then readjusted in order to survive especially when facing illnesses that form as a result of the conditions of the desert environment. Shifting Agentive Strategies in Order to Survive The Sonoran desert presents a wide open terrain free of structural constraints; it is also an area with limited border security. Heat exhaustion, hypothermia, drowning and dehydration serve as some of the common causes of illness and death as migrants travel across the frontera (Whitaker, 2009). The harsh climate, rugged topography, and expansive nature of the desert have led many people involved in this research study to 122 experience health related problems such as fatigue, dehydration, exhaustion, fever, chills and anxiety. The trips through the Sonora desert are not jaunts through the park. Even if the undocumented immigrant can successfully make it through one of the border towns in Arizona such as Nogales; they must venture through the “parched landscape north toward Phoenix or Tucson” exposing them to the elements (Eschbach, Hagan & Rodriguez, 2003, p.43). The Sonoran desert’s difficult climate which ranges between 40 and 50°C usually leads undocumented individuals to walk at night in order to reserve their energy and hide from border security during the day. The drastic changes in climate can cause fevers to soar and colds to build especially if the immigrant is unprepared for the extreme changes in weather from night to day. In many of the interviews I conducted, individuals surrendered their agency to coyotes in order to make it across the border. However when these individuals or their family members were faced with a health situation related to crossing the border they actively chose to make decisions in order to ensure survival. I sat in 36 year old dry cleaning attendant, Patricia Suarez’s apartment in Grovenburg as her two children ran up and down the stairs playing tag. She said that she was tired from the long work days but that the life she led in the U.S. was much better than what she was accustomed to in Mexico, “where one survives day to day”. She reflected on what she had to endure in order to make it across the border and how others acted on her behalf. Patricia has lived in Grovenburg for 13 years and only traveled back to Orango once after three years in the U.S., for the funeral of her mother. She explained how when she returned to the U.S., after the funeral, she was accompanied by her brother and brother of her brother in-law. All three paid to be crossed into the U.S. illegally by a 123 coyote putting their faith in his prowess as a human smuggler, unfortunately all the precautions and details he took to get the group from one country to another were challenged when his perfectly planned journey became the site of illness, On her second trip to the U.S., Particia Suarez developed a very high fever while walking through the desert with her two family members. Patricia said, “the desert was a very, very hot place to be walking and during the journey the heat made my fever worse”. She said, “I was very hot but I felt chills all over my body and was sweating so much”. Patricia grew worried and felt that there was no help in sight. She knew that she had to press on as the coyote led them through the desert, but the chills made every step feel like an eternity. She said nothing, knowing that complaining would not help her situation but the pain and exhaustion were visible to her companions through her labored breathing. The men traveling with her knew that if they found a store and ventured inside, they risked being caught but they also knew that Patricia needed the help. Eventually the men decided to take the risk. They stopped and found a small gas station where they were able to purchase some Tylenol and water which served as Patricia’s saving grace for the rest of her journey. Had the men not acted when they did, Patricia said she didn’t know what would have happened while sick in the desert. As highlighted in the case of Patricia individuals have the ability to affect their present situation through influencing the actions of others, in order to achieve a desired outcome that supersedes external influences. Patricia’s emotional and physical state led the men that accompanied her to act on her behalf. According to Bandura (2006) proxy agents commonly act on behalf of others, as seen in the case of parents who make decisions for children, and politicians for the general public. In this case strong 124 undocumented immigrants acted on behalf of those weaker undocumented immigrants who fell ill. For undocumented immigrants like those presented in this chapter, choices are often made on behalf of those individuals who are unable to achieve a desired outcome because of their physical or cognitive incapacity at a specific time. Such choices can have an impact on the proxy agents themselves putting their lives at risk in order to save another. While interviewing two women in Orango I heard the stories of their family member’s crossings. Although these women had never crossed the border themselves, they were keenly aware of the risks their loved ones took in order to protect a family member who had fallen ill during the cruzada. Betty Ruiz, one of the women, a housewife, shared how her husband risked his own life in order to save the life of his brother-in-law, a man with high blood pressure. The following example illustrates how two family members banded together as a collective unit to act as proxy agents making decisions for the survival of a fellow paisa. Most people cross through Arizona; a vast desert that sometimes sees no end. Betty’s husband was accompanying his 45 year old brother-in-law across the border when the brother-in-law became very ill and could no longer walk. Betty’s husband and nephew were traveling with him and had they not been there to support the sick family member they were sure the coyote would have left him behind. The coyote kept on saying “leave him behind, leave him behind”. Between Betty’s husband and her nephew they dragged him most of the way and he just got worse and worse as his blood pressure continued to rise. “My husband said that he knew he was risking his life carrying his brother-in-law because they were at a much slower pace and all three men ran the risk of 125 being left behind”. Betty said that her husband told his nephew, “If they catch us they catch us. But how can we possibly leave a family member behind to die. He would do the same for us.” The statement at the end of the previous example, “He would have done the same for us” serves as a testament to the understood pact of survival between a collective unit or micro-community of undocumented individuals trying to cross the border. The collective goal of this group was to make it across the vast territory under the guidance of a coyote who they had put their faith in to take appropriate courses of action. When the coyote demanded that the weakest link be left behind, two family members made a choice in the interest of the collective goal to survive as a group, which could have had detrimental effects on their own well being. As we have seen, individual agency surrendered over to coyotes who are expected to act in the best interest of the undocumented can backfire as the coyote’s intentions and planned courses of action change to serve their own interests. As circumstances change and one is faced with the harsh climate and conditions of traveling across the border so too do their agentive strategies in order to survive. One woman I spoke with named Antonieta Rangel, a 46 year old dish busser and mother of three sat down at her dining room table to speak with me in her Grovenburg apartment. When I asked her about her experiences crossing she quickly put her hands to her forehead shaking her head in dismay. She said, “no, no, it was a circus everything that happened to me. That’s why it’s better I just stay put here in the U.S.” Her experience demonstrates the harsh conditions and physical suffering people must endure in order to protect and ensure the safety of others with no agentive power, such as infants and children. She spoke of the sacrifices 126 she had to make with tear filled eyes remembering the suffering she and her baby endured during the crossing. Antonieta crossed the Sonoran desert into Phoenix in the back of a truck bed with her 10 month old daughter, 7 year old son, and young niece. Once they arrived in Phoenix at two a.m., the four of them had to wait in an apartment until the next leg of the journey. They ate when the coyote’s assistants came in to feed them, a burrito or a hamburger. Antonieta was the only one who ate the burrito and she said she felt sick immediately. She tried calling the coyote but after he dropped them off at the apartment she never saw him again. By morning she said she had chills and felt like vomiting. The coyote’s assistant arrived and told Antonieta to prepare for departure and she explained she was sick and scared to travel. The assistant asked if she wanted to return or continue on. She pondered for a moment and then decided to carry on, especially after all that she had already endured. At 8am a van arrived packed with other travelers headed to Atlanta. Antonieta remained gravely ill. She could not keep down any food or fluids; everything turned her stomach. She knew it was a viral infection but she didn’t know how it got in her system. During the trip the van became extremely hot. At the start of the trip she attempted to give her daughter some water from her only jug and it fell from her hands. She saw the water make a mini river flowing away from her, trickling along the floor of the van. She wanted to scream for her water and push to get what was left in the jug but she remembered the coyote’s rules. All were told to stay quiet and not move at all during the journey. Antonieta said, It is in moments like those that one realizes how difficult of a situation it all is…We were so uncomfortable, we were like sardines and I couldn’t even stretch 127 to move the jug. My daughter became very desperate and upset because she was so thirsty and hot. I tried to keep her very quiet but the baby ended up biting me several times out of thirst and frustration. Antonieta bore the pain as any protective mother would. She thought she was going to die with her baby clutched in her arms, as her fever soared and she suffered excruciating stomach pain, with no where to relieve herself. Finally the driver stopped to buy her coffee but Antonieta could not drink it, eventually he bought her some PeptoBismol. She remained sick and dehydrated until she arrived in Grovenburg there her nephew and his wife gave her antibiotics, but that did not alleviate her symptoms. Her family members eventually took her to the hospital in Grovenburg where she was treated for food poisoning. Antonieta, followed the instructions of the coyote blindly accepting the food and resources the coyotes provided assuming these human smugglers had her best interest and survival in mind. However, there came a time when the coyote’s guide deflected the decision making back to Antonieta, asking her if she was going to continue on or return to Mexico. Antonieta made an individual choice to endure the pain of her stomach cramps and press on in the interest of the children that accompanied her. She served as a proxy agent making decisions in the present moment that would ultimately affect the future outcomes of those children. She quickly strategized and endured the pain of a thirsty child’s bites in an effort to subside their yearnings for water. In the case of Patricia Suarez, Betty Ruiz’s family member and Antonieta Rangel the harsh conditions of border crossing created health complications for these individuals that they had to manage with limited resources. In order to survive they had to make on the spot choices that influenced their final outcome. One of the essential contributing 128 factors to the functionality of agency is that the individual must believe in their self efficacy, which is their potential to truly influence the outcome of a given situation by way of personal, proxy or collective agentive strategies (Bandura, 2006). In all three cases the individuals believed through self-efficacy that surrendering their individual agency to the coyotes crossing them was their best chance at survival. When faced with health concerns and the unforgiving nature of the cruzada all three cases also demonstrate how people make use of agency at multiple levels and reformulate strategies for survival depending on the situational context of the moment. In all of these cases those closest to the traveling immigrant either depended on them for survival or the immigrant depended on those closest to them to ensure their own survival; each playing a part in a small but necessary shifting set of agentive strategies in order to make the journey across the frontera. Starring Death in the Face in Order to Survive the Cruzada The stories of the immigrants I interviewed in both Grovenburg and Orango heed a warning that at times, ones chances of survival are a matter of whether or not luck is on their side. Several of the immigrants I spoke with described saving their money, and following the thousands of others that make the same trip with hopes of improving life circumstances for the families they leave behind in Mexico. Their stories are eerie and truthful describing how the risks of death in the middle of the desert are real. These stories also serve to tell a story of traversing boundaries and trying to survive in harsh terrain, in order to make it to the U.S. These individuals remained active in determining their outcome even after they surrendered their agency to the coyote. The stories presented in this chapter highlight the unique strategies people in a liminal state utilize, 129 when faced with no alternative but to believe in and execute plans of action, for their benefit or the benefit of those closest to them. I found throughout my interviews with those who made the jump across the line that the human will to survive, in the most challenging of situations, served as the cornerstone to self efficacy. If people don’t believe in the possibility and effectiveness of their actions they remain passive agents submitting to the environment that crouches down upon them. “Unless people believe they can produce desired effects and forestall undesired ones by their action, they have little incentive to act or to persevere in the face of difficulties”(Bandura, 2009, p. 9). For these immigrants, wanting to survive and get through the difficulties of crossing was motivation for them to remain active players in their own destiny and make decisions at multiple levels that they believed would change their outcome. The cases serve as a window to understanding forms of governmentality and their impact at the micro-level. In this case forms of governmentality can be found in institutional reforms such as the 2005 Secure Border Initiative which added 370 miles of additional fencing and enforcement, especially in urban areas along the border, pushing individual undocumented immigrants into inhospitable and remote areas that increase chances of death and high physical and financial crossing costs (Whitaker, 2009). However, as the stories suggest people and communities of people react to such governmentality by counteracting with the limited active agency they posses in such situations. In some cases forces beyond the individual’s control constrain the decision making process creating unforeseen challenges to permeating the physical border. These forces can be understood as a type of structural violence or indirect violence embedded in social hierarchies that can lead to forms of structural vulnerability, in this case poor 130 health and death for this marginalized population (Quesada, et.al, 2011). The undocumented immigrants I heard from reported situations where they had to think on the spot making decisions they had not anticipated regarding their health and well being. In many cases these individuals had their agency stripped away from them by forces, circumstances and individuals with much more structural power in the migration process. Throughout my interviews I encountered a common theme; when stripped of augmentative forms of agency, these immigrants made an active choice to surrender their agency to a network of individuals who specialize in the lucrative business of people smuggling. By making the strategic choice to surrender their agency and follow the orders and directions of the coyote and other guides, these immigrants hope for better chances of survival. Once the journey begins and they find themselves, lost, abandoned, hurt or suffering illness; these individuals reformulate their agency to incorporate strategies for survival, that protect both themselves and those closest to them (i.e. children, spouses, kin and other undocumented immigrants) while crossing the border. Unfortunately, as we saw in several of the cases, the harsh conditions of the desert and uncertainty of a network of individuals who may not have their best interest always in mind caused many of the immigrants to experiences heightened illness responses and conditions that stayed with them throughout the journey. While at first it seemed to me that simply arriving in the U.S. was reason enough to celebrate, the fact that many arrived with serious illness, as a result of the harsh conditions they endured along their journey, caused me to wonder: what types of strategies these new immigrants utilized in a foreign environment in order to attend to these and other health needs? 131 Chapter 6: Navegando Michigán, Piecing Together Resources in a New Culture of Medicine When Fernando, an illegal immigrant, returned to the U.S. for a third time, he chose to take with him his young wife Yadira. Arriving in Michigan the young couple found themselves in a confusing place, “it was as if our eyes were closed,” explained Yadira Segovia of her first few days in the U.S. The language, culture, environment and health care system were all new to them. Navigating the intricacies of “not knowing what resources existed or where to find them was a scary process.” During their first few years the Segovia’s had no insurance while Fernando bounced back and forth between construction jobs. The couple had to link up chains of information, through community and friends, in order to acquire the health care services they needed for their daughter, who was born in the U.S. with eye problems. After speaking with other recent immigrants from their hometown, the couple was pointed in the direction of the County Health Plan and Medicaid for their children. The Segovias grew frustrated while trying to manage their daughter’s eye condition. The family was often put on waiting lists and struggled to find a consistent physician, let alone a prestigious one, that would take on new Medicaid patients. At the time of our interview Fernando had just switched to a different construction company that offered good pay as well as health benefits. Even though the family was undocumented Fernando’s employer offered insurance to it’s paying employees. The health benefits were one of the main reasons Fernando made the switch over to that particular construction company. He received private health coverage for his family which served as their primary insurance; covering physician visits, dental care, and vision care. Because Fernando only worked 6 months out of the year, the children were also able to qualify under the State Children’s Health Plan as their secondary form of insurance. With new combined coverage through government funded care and private insurance, the Segovias were able to take their daughter to an eye specialist in a timelier fashion. The family was living the American dream; they worked, reaped the financial benefits, and had health insurance. The example above demonstrates the fluidity with which immigrants weave in and out of multiple health systems in order to access health related resources for themselves and their family members, as situations change and opportunities arise. The health care system in the United States is made up of three systems of health care coverage: employer based private insurance, government funded and out of pocket paid care. The majority of working Americans receive their insurance coverage through the private insurance market, usually through their employer. Others receive coverage through government programs like Medicaid, which provides health coverage for low- 132 income American children and adults, medical and long-term care coverage for people with disabilities, and assistance with health and long-term care expenses for low-income seniors (Families USA, 2014). Other federally funded and state operated programs like the State Children’s Health Plan (S-CHIP) administer coverage to the children of low income and middle class working American families. Additionally, at the local level there exist programs like the County Health Plan which provide basic short term benefits for those not covered under Medicaid (Rovin, Stone, Gordon, Boffi, & Hunt, 2012). The County Health Plan covers primary care visits, x-rays, out-patient lab tests, prescription drugs and some other basic care for nominal co-pay. The third option is out of pocket care where the patient seeks out and pays for treatment in private doctor’s offices, ready care facilities, etc. paying up front fees for services received. Although these are the options that are available in the United States, only a few of the immigrants interviewed in this study were able access care through the Private Insurance Market; as we saw in the case of Fernando and Yadira Segovia, and such experiences were often short lived. The majority of the study participants in Grovenburg worked in jobs that didn’t offer their families health coverage through a private insurer. This was especially true for the undocumented as their employment is not kept on the books and their social security numbers are not valid. A few of the American residents and citizens who participated in this study were offered the opportunity to get private insurance through their employers, but all rejected the offers due to the high premiums and instead actively made strategic alternative choices for care. Gaining access to any of the three health coverage options and finding the necessary resources to accommodate ones health needs in the U.S., regardless of 133 immigration status, can prove to be a challenging endeavor. The participants in this study drew upon various forms of agency and agentive strategies in order to navigate these health care options, given their particular needs. Multiple unconventional measures are often used by transnational immigrants in order to navigate a complex health care system that can prove daunting to even U.S. citizens with health care coverage. Rein (2007) argues that on average Americans receive appropriate health care only about half of the time. It can be expected then that those new immigrants or immigrants with Limited English Proficiency (LEP) may encounter additional barriers in accessing appropriate health care. Bandura (2006) argues that current health practices focus on the supply side of medical encounters where there is a pressure on health systems to ration, delay and cut health services in order to reduce health costs (p.176). Using an agentic model of health that challenges these policies I focus more on the demand side, meaning what people require in order to achieve optimal health and how they meet those needs. I am interested in what strategic choices people make in order to gain entrée into health systems and overcome institutional and cultural barriers to care. This chapter presents specific medical encounters as case examples for understanding the passive and active forms of strategic agency that are used by transnational immigrants in order, to navigate the health care options of the U.S. According to Bandura (2006) agency is the power we have to shape our functioning and life circumstances. We are not simply on-lookers to our life situations, instead we have influence and that influence takes various forms that we use to our advantage especially while navigating the health care systems. Similar to those living in Mexico, those living 134 in Grovenburg make strategic choices to utilize agency at the individual, proxy/family, and collective/community levels in order to alleviate their health care needs. Living in the United States as an immigrant creates needs related to accessing health care that are different than the needs one may have living in rural Mexico. While gaining access to certain medical facilities or paying for the treatments needed at such facilities may prove problematic for the rural poor in Mexico; in the U.S. lack of language proficiency, lack of formal insurance, lack of comfort/trust with the U.S. health care culture serve as examples of some of the unique conditions that emerge for Mexican immigrants as they navigate new systems of health. Given that the situational needs of new immigrants related to accessing health care are different for those living in the U.S., so too are the proxy and community agents at both the local and transnational level that can either ease or complicate courses of action as they take place. Depending on the position of those community and proxy agents involved, one may or may not gain access to additional health related resources and information. In the following cases I present the forms of strategic agency used by immigrants in Grovenburg, Michigan in order to gain access to health systems and alleviate particular health care needs. These examples demonstrate how a community of immigrants in Grovenburg has maintained a link to Orango as a transnational agentic strategy that only functions if the links are also maintained at the individual, proxy and collective agentive levels. Navigating Health Care Locally at the Individual and Proxy Levels While every family I interviewed in Grovenburg made mention of having a family member covered under the County Health Plan, most had each family member covered 135 under a variety of different health plans. One family member might be covered under employer based insurance, another might be covered under the county and the children under a state funded Medicaid program. In order to access care while dealing with various forms of coverage the immigrants I interviewed strategized at multiple levels. They counted on their own knowledge, family resources, and the community at large in order to navigate these various health care options. Many of the participants in this study described their discomfort with the U.S. health care system when they first arrived to Grovenburg. Participants spoke candidly about adjusting to a situation where they felt lost with so many programs and services that seemed to only be available to certain individuals, under certain circumstances. Some were not sure who to speak with or where to go. In some cases I even found that immigrants hesitated in seeking care at particular agencies for fear of being discriminated against by gateway proxy agents, that is, those individuals who serve as intermediaries linking those in need with certain government funded programs. The immigrants I spoke with described how they navigated the system on their own, with their family members and through the community resources available during specific situations. In order to piece together the services available locally, they had to be active agents using individual, proxy, and collective; knowledge, Palanca [leverage], and previous experiences in Mexico as methods for survival. Making sense of the pharmacy. Pharmacies are usually the first stop for many of the new immigrants living in Grovenburg because they are commonly used as primary sources for medically related information and low cost medications in Mexico (Turner, Ellertson & Thomas, 2003). For Mexican immigrants there is a certain level of comfort in seeking out resources at the pharmacy because such behavior is commonplace in Mexico. 136 In the U.S. as is the case in Mexico pharmacies are relatively accessible, easily recognizable and usually have the necessary items to treat minor illness, thus promoting self care. These new immigrants shared that over the counter medication is usually their first means of treating family illness especially when they do not have insurance for prescription drugs or do not feel comfortable going to a doctor in the U.S. for whatever reason. Many said that a major challenge was that most pharmacies do not have Spanish speaking staff or pharmacists. In some cases the immigrant is left to use their own knowledge and previous experiences while determining what medication to purchase for specific symptoms. Understanding U.S. pharmacies on their own presented multiple challenges for the Mexican immigrants in this study, especially for those individuals with LEP. In some cases, I was told that individuals determined what medicine to purchase based on the pictures they saw on the outer box and decided approximate dosage based on their previous experiences taking similar medications in Mexico. Most of the undocumented immigrants learned their way around the pharmacy as best they could and made individual strategic agentive choices based on their limited knowledge about the medication and dosage instructions in the U.S. Although making such decisions about medication may seem like a useful individual strategy there are many problems involved when undocumented immigrants serve as individual agents and self medicate with over the counter drugs. For instance according to Frøkjær et al. (2012) link the use of over the counter medication from local pharmacies to medically related problems. Individuals could take the wrong dose, they could take the wrong medication for specific symptoms, they could become dependant, and they could choose to not seek further medical 137 attention or delay care. However, at times, self medicating with over the counter drugs is the only viable strategy when one is new to an area and unfamiliar with how to access other forms of health care. Unfortunately, certain reforms aimed at protecting the welfare of “the people” have resulted in limiting resources for this particular marginalized population. The Combat Methamphetamine Act of 2005 for instance, has established new legal requirements for the sale and purchase of pseudoephedrine, ephedrine, and phenylpropanolamine in order to limit the illegal production of Methamphetamines. The drugs listed are most often used as over the counter medications for congestion caused by colds, sinusitis and allergies. Individuals must present state issued or other appropriate identification and their names and addresses must be documented by the seller for a period of time. Such laws place serious unintended limitations on undocumented immigrants seeking over the counter medications. These immigrants, who as we have seen seek out treatment through pharmacological care, lack formal identification and avoid documentation in order to avoid deportation. In several conversations with families involved in this study, I was told that these particular restrictions were influencing these families to consider self deportation. One man told me that, the government was making it impossible for he and his family to survive. He said, “we don’t have health insurance and now we can’t even get medicine to treat a cold from the pharmacy. We have to ask people with I.D. to buy us the meds. At least in Mexico we would be able to buy medicine”. In other instances strategic agency at the family level, in the form of consulting elderly family members for advice on what over the counter medications to take, serves 138 as a form of comfort for the “lost” new immigrant. Pylypa (2001) argues that many Mexican immigrants get health and medical related information from pharmacy attendants and other non-doctors, such as family members, who do not have sufficient training to provide sound medical advice. However with limited health care option availability, a lack of trust regarding the U.S. health care system, and family members serving as an accessible primary source of information; getting advice from these untrained individuals may be one of their only ways of accessing information and resources within the pharmacy. Laura Gutierrez, a 26 year old mother of three, strategically chooses to rely on family members to make decisions for her in the pharmacy because they speak English and are more familiar with American over the counter drugs. Since arriving in Grovenburg Laura has made great use of the local pharmacies because she is uninsured. However, even though Laura can access pharmacies understanding what the labels on medications say still presents a problem for the limited English speaker. Laura often consults her mother-in-law about which medications to purchase before going to the pharmacy and depends on the limited English of her boyfriend Ricardo, in order to steer her way through the much needed pharmacy. Neither she nor her boyfriend has formal health insurance and her children are covered under the state funded CHIP. Laura Gutierrez says that when she is ill she goes to the pharmacy and purchases over the counter medication. Most of the time, she follows her mother-in-law’s instructions and buys alka-seltzer “because it seems to relieve many ailments”. Laura has no insurance so she tries to dress appropriately for the weather. She said, “I try not to catch anything. I rarely go to the doctor because I don’t want the bills I try to just go to 139 the pharmacy”. Her boyfriend is able to read some English and figures out what over the counter medicines might work according to who is ill in the family and their symptoms. When I asked her what she thought the situation was like for other undocumented individuals in the areas. Laura said, “I don’t know how other undocumented people get their help, especially if they don’t have family nearby”. As we can see in the example of Laura, U.S. pharmacies can be frustrating places for any person entering one for the first time. Laura often manipulates a purely English speaking environment and gets the resources she needs, out of the pharmacy, by trusting others close to her who have pharmaceutical and English knowledge she does not. But problems in pharmacies are not always limited to those with relatively no experience utilizing the U.S. pharmacy. Even for those who are well adjusted and have different forms of health coverage; navigation of pharmacy policy, regulations, and bias calls for strategic manipulation of the system in order to fully gain access to certain resources. Fernando and Yadira Segovia explained how even though they had private insurance based care along with Medicaid for their daughters, they often found themselves frustrated with the level of attention and quality of service at their local pharmacy. The Segovias often felt discriminated against by the staff and frequently had to go out of their way to prove to the pharmacists that their insurance was valid. Van Van Houtven, et al.(2005) argue that perceived discrimination is associated with treatment delays and delays in filling prescriptions at pharmacies which can have negative effects on ones health outcome. The Segovias spoke candidly about their experience of discrimination while waiting for a necessary prescription at one of the 140 local pharmacies and how they had to turn to an influential community member in order to be acknowledged and served. Fernando Segovia explained, At the pharmacy we had to wait in long lines, they constantly asked for our I.D., we were told that the computer was telling the pharmacists that there was a problem with our insurance, and they would tell us the medicines would be ready in 20 minutes when the pharmacy would take hours to prepare them. Eventually Fernando and Yadira took the situation into their own hands and called a Latina friend who worked for the County Health Department. They asked her to speak to the pharmacists. The friend arrived and complained about the mistreatment the family had suffered and since that day Fernando and Yadira said that they had not had problems with their insurance at the pharmacy. Fernando and Yadira found it necessary to navigate the world of over the counter drugs with strategic agency at multiple levels. They first succumbed to the procedures and policy of the pharmacy attendants. When they were not getting the services or attention they sought out on their own, Fernando and Yadira, quickly called upon a friend with palanca to get what was needed. Her position as an employee of the health department was situated within a historical context that gave her access to valuable knowledge. Her insight and experiences with the language of health politics, billing information, and insurance were things the Segovias had not been able to access as undocumented, uneducated, non English speakers, with new insurance. For some new immigrants, other factors such as limited English proficiency, lack of transportation, and lack of familiarity with the area may additionally inhibit their ability to access pharmacies or get information from pharmacy attendants in a foreign language. Many of the participants in this study shared how pharmacies may not provide 141 all that they are looking for when they first arrive in the U.S., in order to get over the counter medications and supplies in a one stop shop for both health and cultural needs some participants mentioned their use of Tiendas Mexicanas [Mexican Grocery Stores]. According to Coffman, Shobe & O’Connell (2008) many Mexican immigrants find multiple health related resources in these stores and can even access prescription medications at some of these stores. These tiendas serve as resources for strategic agency, allowing the immigrant to rely on an extended form of their home community while living in a new location Antonieta Rangel, the same woman who arrived to Grovenburg with a case of severe food poisoning explained, “When I first arrived it was very difficult to get the medicine I wanted because I was only familiar with Mexican brands and I spoke no English”. Soon after her arrival she was told by other community members that she could find many of the medicines she was familiar with, at the local Mexican grocery stores in Grovenburg. Until Antonieta was able to access county health plan coverage, she frequently bought medicine and other health related supplies at the Mexican stores. In this case community members, already familiar with the local sources for care, serve as a collective resource necessary for new immigrants to understand and navigate alternative choice in their new surroundings. The recommendation of Tiendas Mexicanas by several community members provides an avenue for accessing an array of items, such as herbs, salves, and medicines new immigrants are comfortable utilizing. Although these stores may not provide prescription drugs, they do serve to alleviate minor health concerns for the immigrant and they cater to their needs in their native language. These stores and their familiar products serve the inherent needs of immigrants with seemingly 142 nowhere else to turn until they become familiar with their new surroundings. The stores are thus a symbolic source of power giving the immigrants individual agency while also maintaining a cultural link to Mexico as they navigate a new community in the United States. While encountering new systems of change, such as the U.S. pharmacy, immigrants in this study relied on their own knowledge, the experiences/opinions of family members, or the palanca of community members as adaptive strategies for addressing immediate health care needs in a new country. Whether they used agentic strategies at the individual, family or community levels or a combination of two or more; the choices made maximized health resource potential for the new immigrants in a new environment. Using intentionality, forethought, self reactiveness and self reflection with regard to navigating pharmacies and tiendas in a new environment, proved to be the essential first steps in navigating the U.S. culture of medicine Navigating out of pocket care. When going to the pharmacy and seeking over the counter drugs is not enough and new immigrants have not yet enlisted in federally funded health programs, or are without insurance coverage; they are usually left between a rock and a hard place. Although there is much controversy over the use of emergency rooms by individuals without health insurance, which may include the undocumented, most of the transnational immigrants in my study only mentioned emergency rooms as a last resort. Participants mentioned fear of incurring a multitude of bills or developing a “bad record” in the U.S., as contributing factors to not wanting to utilize emergency rooms. As a solution to their immediate health care needs many of the immigrants sought out less expensive forms of preventative care and regular physician visits. 143 Among the community of Oranguenses living in Grovenburg, word had spread of a Latino doctor with a private practice about an hour northeast of Grovenburg who accepted cash for his services. Several of the immigrants in this study spoke about their positive experiences and comfort level with this particular doctor. They described comfort experiences where, as Kolcaba (1997) argues, specific needs were met with ease and transcendence in one or all four contexts; which include the physical, psychospiritual, social and environmental. Comfort essentially equals a holistic experience of fulfilled needs. Identifying comfort and trust as essential characteristics in a doctor patient relationship, led certain immigrants to seek out of pocket care outside of their immediate community. Fifty-three year old construction worker Victor Marinez was the first person who mentioned the family doctor with a private practice, who seemed to serve the immediate needs of the local uninsured Latino immigrant community. Victor sat in his house and explained his positive experiences with Dr. Juan in the following way. “I like to go to that doctor because he does not require appointments, he takes walk-ins. In Grovenburg all the doctors require appointments and then one has to wait weeks for an appointment.” According to Victor, “Doctor Juan will always see a walk in patient and one always leaves with their problem solved.” Victor was very pleased with this particular doctor because he was from Latin America and spoke fluent Spanish. Victor said, “it’s not a problem to drive almost an hour away because waiting one hour is better than waiting for fifteen or twenty days to see a doctor” Throughout my interviews in Grovenburg, I found that comfort has a great deal to do with how, when, and where these individuals, families and the community at large 144 strategize to seek care. Money was not as inhibitive a factor as I had thought it would be. Instead my participants, especially those without insurance, shared that they much rather preferred to pay in cash and drive a long distance for doctor consultations instead of accumulating high emergency room bills. Owing large sums of money left participants with a high level of discomfort and led them to make choices for other avenues of care in their extended community. Additional interviewees mentioned paying out of pocket for services as both economical and necessary when they lacked private insurance coverage. Rosa Carmona, whose husband was one of the first Oranguenses to settle in Grovenburg, told me of how her husband had grown very comfortable with a Mexican female doctor who had worked at one of the government clinics in Grovenburg. After several years in Grovenburg and after having built a large patient list, the doctor was to open her own private practice an hour south of Grovenburg. Rosa shared that her husband was so comfortable with the way the female Mexican doctor had treated him that he along with others from the community continued to seek medical care at her office an hour away. Establishing a certain level of trust between doctor and patient was very important for the majority of the participants in this study. Many said that there was not enough confianza [trust] with the American doctors. It comes as no surprise then that many of those interviewed mentioned traveling long distances to seek treatment from Latino doctors who had established rapport. For many of the immigrants that chose to travel distances and pay out of pocket for physician visits, their experiences are reminiscent of seeking care in Mexico from doctores particulares [private doctors] who have built rapport with families over the years. Patients knew how much they would be charged and 145 anticipated a comfortable atmosphere where they were treated with civility, in their native language. Utilizing government funded care options. Throughout this study three common resources continuously emerged. The first was the County Health Plan, the second was immigrant’s gateway individual for accessing the County Health Plan; a woman by the name of Josefina and the third was the bilingual health clinic run by the Arch Diocese of Grovenburg. At the bilingual health clinic the immigrants were able to use the tarjetita Blanca [little white card] issued through the County Health Plan, in order to access services. Unfortunately, some undocumented immigrants arrive to the Grovenburg area with little or no knowledge of what resources are available to them. They find themselves seeking assistance in government funded care settings not because they make an individual agentic choice to do so but because they turn to family and friends for assistance and these more experienced and knowledgeable individuals point them in that direction. Take for example the case of thirty year old Mariela Zavala, a woman who now has coverage through the County Health Plan. Mariela, who now takes English classes and is in the process of becoming a resident, found her first few months in Grovenburg so difficult that she didn’t even know the city had any clinics. Those months were especially challenging as she had no insurance and was not covered under any federal, state, or local services. During our interview I asked her how she navigated an unknown system and she explained her actions in the following way. “It was very difficult for me, I started hemorrhaging one day and I didn’t think anything of it at first; I just assumed it was a heavy period.” However, the problem 146 persisted for a very long time. Mariela became worried when the bleeding did not stop and she didn’t know where to go for help. Mariela told her sister-in-law, a woman who had already lived in the U.S. for eleven years, about the bleeding and who in turn consulted her neighbor. The neighbor then took Mariela to the bilingual health clinic. They checked her over for free but referred her to a gynecologist. Dr. Jones, the gynecologist that works closely with the bilingual clinic, said that the hemorrhage was due to a miscarriage she had suffered a couple of days prior. The doctor explained to Mariela that she was very lucky that he was able to bring down her fevers and bleeding because her life was in danger. Although Mariela did not have to pay at the clinic she did have to pay out of pocket for the appointment with the gynecologist. Dr. Jones, was very accommodating according to Mariela, “he allowed me to set up a payment plan for the services I received.” As a new immigrant to the area with no prior knowledge of the health culture in Grovenburg, Mariela was unable to make direct individual choices to benefit her health. Instead, she had to make an indirect active individual choice which consisted of surrendering over her agency to her sister-in-law and her sister-in-law’s neighbor (both proxy agents). These women then linked Mariela with the community resources necessary in order for her to achieve an optimal health outcome. Mariela strategized by seeking assistance from someone she felt comfortable with, her sister-in-law. The sisterin-law was already acculturated sufficiently with her surroundings to involve a knowledgeable neighbor; who then linked the immigrants to the bilingual health clinic. Like Mariela, Susana Chavez felt lost when she first arrived from Mexico. During our interview she explained that she had recently been enrolled in the County Health 147 Plan. I asked Susana how she came about getting health related information, where she accessed enrollment forms and information on the various types of insurance and health plans available to her family members. Susana shared that Josefina is her first point of inquiry; answering all of these questions and making sure that Susana is pointed in the right direction. Josefina serves many roles as a bilingual community resource, an educated Latina, and employee of the county health department. The structure of local government funded health care has created several of Josefina’s identities. How both she and those in need of her services (many poor undocumented immigrants) understand her multiple roles, has a bearing on the types of services rendered through this proxy agent relationship. Josefina is familiar with the ins and outs of multiple health care options because it is her job to know this information and serve as a resource, however what she does with her knowledge and who she chooses to help is wholly dependant on her own experiences with larger institutional structures. Josefina’s multiple roles, embedded in her daily interactions with those who seek her assistance, affect the types of resources those in need will receive. Her role as a gateway into the realm of health care for new immigrants, illustrates Stryker & Burke’s argument that structures of power are embedded in social relations, creating identities and interpretations of those identities that affect social behavior (2000). Josefina’s multiple identities allow her to weave between the institutional policies of health care and the undocumented Latinos seeking out services for care and either connect or disjoint their union. Alma Marinez, another CHP recipient concurred by saying, “if the County Health Plan doesn’t cover something one must fill out applications for assistance with Doña Josefina and hope that she is willing to help you and can find a program that might help.” 148 In some instances new immigrants transition in and out of health systems not knowing which system might best serve their needs or which options they actually have the rights to access. In the case of Antonieta Rangel, the fear of being covered under a federally sponsored program, while being undocumented prompted her to cancel coverage. Antonieta explained the misunderstanding to me while practically in tears. “I was covered under the County Health Plan but an emergency gallbladder surgery and long stay in the hospital left me with enormous bills that were not covered through the County.” Antonieta explained that just when she started to worry about how she would pay the bills some paperwork arrived. Antonieta tried to make sense of the paperwork and believed it to be the forms needed for “the association that helps people that can’t pay.” Antonieta filled out the paperwork using her false social security number and then went to speak with Josefina. Josefina quickly explained that if Antonieta qualified for the emergency Medicaid program she was not allowed to have the County Health Plan. Antonieta grew worried and said that she, “didn’t want to have problems with the government” so she asked Josefina to cancel the temporary Medicaid assistance so that she would not loose her County Health Plan coverage. Shortly there after Antonieta was in an automobile accident and suffered a minor injury. When she went to seek medical assistance, she found out that not only had she canceled her Medicaid coverage but her County Health Plan had also been canceled when she applied for Medicaid leaving her with no medical financial assistance. Antonieta like many of the immigrants in this study tried to understand various health care options at the individual level and made agentive choices according to her immediate needs. In this case it was only after she spoke with a bilingual community 149 resource, familiar with policy and plan coverage guidelines, that she was able to fully understand the negative ramifications of her preliminary individual agentive choices. While trying to correct the problematic situation that developed from weaving between health care options, Antonieta was left with no coverage for her hospital stay or treatments. If Antonieta had made a strategic agentive choice by proxy and consulted Josefina about Medicaid and how the program’s coverage extends to the undocumented in emergency situations, she perhaps could have avoided losing her health plan coverage. Utilizing complimentary & alternative medicine. During the course of my study I found that there were frustrations with government funded care and alternatives were sought out at times to ease the desperation of having to wait for care. Although the majority of participants were very grateful to have access to the County Health Plan the majority also grew tired of the long lines and the cumbersome referral system utilized for anything other than a primary care visit. There are many studies on the use of alternative medicine in the Hispanic community (see for example: Graham et.al, 2005; Rivera et.al, 2002; Trangmar & Diaz, 2008). Although the majority of the cases in this study did not identify Complimentary or Alternative Medicine (CAM) as a sole resource or method for addressing health concerns, a few cases did emerge which identified the combined use of CAM with other conventional means for treating illness. The few cases that presented in this study were consistent with Trangmar & Diaz’s (2008) study in a South Carolina community of Hispanics and their use of Complimentary or Alternative Medicine (CAM). In their study 69% of 70 participants reported that they used CAM when there were no conventional treatment options available; because other family members had 150 taught them to use CAM; they did not receive an appropriate diagnoses; or because they were unhappy with previous medical advice (Trangmar & Diaz, 2008, p.3). Take for example Victor Marinez, already unhappy with the negative treatment he had received several times by way of the U.S. private insurance; he sought out resources and information locally related to CAM as a supplemental form of care. Victor explained, “My wife and I have been turning to herbal remedies and herbal medicines for some time.” Victor said that he likes to purchase books explaining home remedies and he frequents the local homeopathic, vitamin, and natural remedy stores looking for natural cures for his ailments. His grandmother taught him that modern medicine is not as good as herbal remedies. “The added chemicals are not good” in his opinion. He has read up on the effects of such added chemicals and he is sure herbal remedies are the way to go. Victor, along with others, mentioned various home remedies that did not require medication or were used in combination with other medications as means for managing their health. Almost all of the participants in this study mentioned their conocimineto [awareness/knowledge] regarding home remedies. They spoke about how home remedies were commonly used while living in Mexico or by other family members, but most of the participants mentioned over the counter drugs and prescription medication as their first line of defense in the U.S. Perhaps this is due to the ease with which these individuals can access medication at local pharmacies or perhaps it is because, as one woman said, the natural resources they are familiar with using to sanar [cure], like hierbas [herbs], are difficult to find in Grovenburg. When I inquired about the use of alternative medicine or therapies, four Grovenburg participants mentioned prayer and faith as very important tools used in 151 combination with conventional medicine to address ones health needs. Fifty-five year old, uninsured, Adrian Flores; who was on Dialysis and in dire need of a kidney transplant at the time of our interview, did not rely solely on biomedicine. Adrian turns to prayer on a regular basis, given his multiple chronic conditions and believes that medicine and prayer are best used in combination for his healing. Adrian said, “one has to have faith and not leave it all up to the medicine.” Adrian like all of the other participants in this study used multiple resources, both conventional and unconventional, to address health care needs and weave in an out of health care options/systems. In a similar fashion, Rosa Salinas explained that her fist lines of defense for treating her children when they get sick are Vicks, rubbing alcohol and Prayer. Neither one of these participants mentioned their specific religious affiliation but did place a great emphasis on how much their fe [faith] was a part of the healing process. Navigating Health Care Transnationally at the Individual and Proxy Levels One of the many advantages this group of immigrants has is the ease with which they are able to navigate multiple health care options due to their transnationality. When the U.S. health care system failed several of the participants in this study, they sought out the necessary resources through alternative means which involved their sustained and continued interaction with their community of origin. There were multiple instances where those interviewed shared how their previous experiences in Mexico and comfort with the resources and people in their native country made for an easy transition between the two health care systems. As transnationals these individuals make decisions, take social action and feel concerns that are interlinked between multiple spaces; the resources and information sought out by any one person through these means can be limitless 152 (Mendoza, 2006). Undocumented immigrants in this study were able to access many of the same transnational health resources as their documented counter-parts because of their continued interaction with their hometown and community of origin. Time and space essentially became fairly unbound concepts for those navigating the multiple systems. In order to serve the needs of those immigrants seeking care, the bidirectional flow of information and resources had to remain easily accessible for those taking part in these transnational efforts. Consulting doctors via telephone & utilizing medicine from Mexico. During the course of this study, I found it was more likely immigrants would send health related items from the U.S. to their kin living in Mexico, than the reverse. In a few instances, however, participants did share how there were specific medicines that were very difficult to access in the U.S. and that they requested them from Mexico. According to the interviewees, U.S. doctors did not want to prescribe certain medications that the participants were used to accessing with ease in Mexico. Alma Marinez and Patricia Suarez both identified fungal infections on their toe nails as recurring problems that were never prescribed medication in the U.S. They both expressed how they had sought out medical assistance in the U.S. regarding the ailment but were directed to take care of the infection through cleansing and soaking the foot or rubbing Vicks on the infected area. Unhappy with what the doctors in Grovenburg had recommended as a treatment regimen, both women consulted their family doctor in Orango who wrote out scripts for family members or friends returning to the U.S. These community members and family members served as proxy agents and participated in the transnational process of getting medication from one location to another. 153 During my stay in Orango I lived with the sisters of Alma Marinez. I also served as a proxy agent and became part of the transnational network that was necessary in getting Alma the prescription Medication she required but could not access in the U.S.. While in Orango I was notified by Alma’s family members that she had called from the U.S. and consulted with one of the private family doctors in town regarding her fungal infection. The doctor employed a strategy whereby I would be prescribed the medication Alma had requested and I would then deliver the medication to Alma upon my arrival to the U.S. When I arrived to the doctor’s office the script was waiting for me. The physician only asked for the specific spelling of my name and verification of i.d. in order to write the script out in my name. Alma explained that when her friends had similar fungal infections, while living in the U.S., they were told to clean the affected areas and were not prescribed medication. Alma demanded a solution to her problem and was unwilling to conform to the institutional structures of policy in the U.S. health care system. Instead she took initiative as an individual with personal agency and devised a plan with the specific goal in mind to get the medication she was familiar with across the border. She organized the players from her location in the U.S. but each party involved had a specific responsibility in getting the medication from point A to point B. I had no problem getting the medication through customs but began to wonder, “If I am bringing across fungal medication prescribed to me but for somebody else’s use; what other prescription drugs are being brought across the border legally and illegally through such agentive strategies at the proxy level?” In my conversations with other transnational immigrants living in Grovenburg I realized that if these community members were unsatisfied with the level 154 or type of care they were receiving in the U.S. a quick consultation with a doctor back home usually began a chain of efforts and events that would get the individual the resources they needed in a timely fashion. Mercedes Perez, the Secretary from Grupo San Judas, shared that after a partial hysterectomy due to severe dysplasia of the uterus, a gynecologist in the U.S. diagnosed her with Anemia and prescribed iron pills. After several weeks with the pills she believed that they were not working. Mercedes, a woman that was born in the U.S. often weaves in and out of health care systems. During the course of our conversation she spoke about using free health clinics, establishing payment plans after expensive procedures and being enrolled in the County Health Plan. She frequently serves as her own advocate making personal choices regarding her health care because she is fluent in English and works in the health care industry. However, even with all of her experience as a citizen in the U.S. and her ability to move about the various health care options available, she still relied on strategic agency at the transnational proxy level in order to get the care she was not getting in the U.S. In this particular case the options available in the U.S. for treating her Anemia did not serve Mercedes’s needs. Mercedes told me that she made the choice to call a doctor she was both familiar and comfortable with in Orango. Mercedes explained her situation to the doctor and he recommended a vitamin injection. The doctor, whose wife was coming to Grovenburg to visit family, sent an iron replacement injection with her, who then administered the shot to Mercedes. In order to get the injection Mercedes used proxy agents to filter much needed resources across the border. 155 The case of Mercedes illustrates how individuals can choose to access resources through proxy agents living in Mexico with a transnational connection that serves their immediate need. This example and others found throughout my interviews confirmed that that the consultations with the doctors in Mexico did not stop once the immigrant arrived in the U.S. nor after they had lived their entire lives in the U.S. For several immigrants in this study, the level of comfort between them and their family doctor in Mexico was such that the bond and trust could not be broken by a few thousand miles. These immigrants felt much more comfortable speaking over the phone with the doctor they had known their entire lives especially after seeking care in the U.S. proved unproductive. The cases mentioned above highlight the ease with which both documented and undocumented immigrants living in Grovenburg navigate health care to their advantage. They seek out the necessary available resources at the local level but are not afraid to link up transnational resources at proxy and community network levels in an effort to overcome certain barriers, i.e. U.S. doctor’s unwillingness to prescribe certain medications. Strategic agency by proxy serves as an important avenue for accessing resources transnationally. Individuals call upon the expertise of medical professionals in another country, who then use migrant family and friends to transfer resources from one location to another. Seeking treatment in Mexico. Grovenburg participants who sought treatment in Mexico belonged to one of two categories: those who returned to Mexico for care by choice, as an alternative to the U.S. health care system and, those who returned to Mexico and sought out care while they were there because it was the only system available to them. Several participants mentioned return visits to Mexico, especially in the 90’s when 156 immigration laws were not as strict and the price to cross the border illegally was not nearly as high as it is now. Returning to Mexico for short visits, for a variety of reasons, became optimal occasions for seeking out medical assistance. These individuals were able to navigate a system that was familiar to them and the treatments were cost efficient. In some cases a diagnoses and treatment regimen in Mexico allows the immigrant to more clearly identify their health care needs once they return to the U.S. For example, when Patricia Suarez returned to Orango for the funeral of her mother she knew she would be overwrought with sadness but she also fell into a deep depression. She explained that suddenly dark spots appeared on her skin and a rash appeared on her neck. She quickly went to her family doctor in Orango and was given medication for her depression and the skin rash. She said of her experience with the doctor, “I felt comfortable with the doctor in Mexico because I have known him my entire life, I was pleased they diagnosed me in Mexico that way I knew what I was going to need in the U.S. when I returned”. In this case, Patricia was conveniently able to make health related choices in Mexico that would play an important role in the types of services she would need as follow up once she returned to the United States. By extending her communal network of resources to the doctors available in her hometown during her brief return visit, Patricia was able to seek the mental health care services she needed and have an idea of what she would require from U.S. doctors once she returned. Had she not sought out care in Mexico by a physician that was familiar with her family situation, Patricia may not have been able to seek care in the U.S. She may not have been able to fully communicate her 157 mental health needs or find the appropriate resources among the U.S. health care options because of her LEP and limited experience with mental health services in the U.S. In some cases and in my conversations with doctors running the government sponsored health center, the mere fact that one has an identity tied to the fact that they have lived in the U.S. or are visiting from the U.S. serves as the real source of power for getting quality care in a timely fashion in Mexico. Ones status as “visiting” from the U.S. positions you to receive a certain standard of care in government run clinics. For example, Ester Alvarez, a woman who lived for many years traveling between Mexico and the U.S. explained that she rarely speaks or consults with doctors in Mexico. However, on one occasion she did have to take her son to the local clinic, she was very pleased by the type of treatment she and her son received. Ester Alvarez returns to Mexico annually and her two sons are generally in good health during the family trips back to Orango. One time, however, Ester’s eldest son came down with a cold and Ester took him to the Centro de Salud. At first a little leery about the government clinic, Ester spoke with her brother who recommended she wait until the weekend when a more qualified doctor would be at the clinic to take care of her son. Ester waited as instructed and her son was seen immediately by the director not a pasante [intern] and she was not charged for the visit. Perhaps Ester and her son were treated differently because of their identity as visitors from the U.S., in my conversations with the director of the Centro de Salud I found out that as a service to those visiting from abroad the doctors at the Centro accept and treat the foreign patients free of charge. Ester, a visiting former resident of Orango used her family as a resource in order to access health care while visiting the town. 158 Putting her faith in her brother she asked his advice on where to seek out assistance for her son’s condition. Ester allowed her brother to direct her as to when she should take her son into the Centro. Calling upon relatives who may be more familiar with the system and or surroundings led to a positive outcome for Ester’s son. Ester explained that had she taken her son to any other doctor in the town she would have paid full price out of pocket. At the Centro de Salud Ester’s son was seen quickly and for free. In some instances immigrants, regardless of their immigration status, find themselves without insurance. When facing a chronic condition or having an ailment that is usually not covered by formal health insurance, many choose to delay care until returning to Mexico. I heard many cases of how the individuals would make the decision to return to Mexico in order to access an alternative health system that attends to their specific health related need. Cases like the young undocumented 18 year old who was making a permanent choice to return to Mexico because he could not afford diabetes care in the United States without insurance opened my eyes to the severity and difficulty of living in a state of liminality. In my interview with Jesus, a line cook, he explained that his 18 year old cousin had expended all avenues for financing diabetes treatment and care, with no insurance coverage. Unfortunately the test strips needed for the glucometer were not covered under the County Health Plan, neither were other resources related to diabetes maintenance. After trying to make ends meet and navigating health care options that led to dead end roads the small family unit, Jesus’s cousin and uncle, had to decide whether to stay in the U.S. or return to Mexico. Jesus’s cousin and uncle eventually made a strategic choice at the family level to return to Mexico in order to seek treatment for a chronic condition that 159 they could not afford to treat in the U.S. Here the young man and his father had no other alternative and did not have the luxury of being able to travel back and forth. One of the advantages of being an American citizen is the luxury of being able to return to Mexico for health care. Unlike Jesus’s cousin, American citizens who return to Mexico for health care possess a flexibility and ease that allows them to move from country to country without having to permanently alter their life circumstances. In most cases those living in the U.S., regardless of immigration status, try to navigate the U.S. health care system first. When they are disrespected, ignored, discriminated against or as in the case below, falsely accused, the immigrant may choose to seek assistance in their native country. By being a U.S. resident and being originally from Mexico, these individuals hold a certain transnational ease of access that essentially permits them use of both systems if they have the financial capital to do so. Stay at home mother of two, 44 year old Celeste Cortez told me about the time her young daughter almost died because of a misdiagnoses in Los Angeles. Celeste and her husband were living in L.A. when their young daughter started having gastrointestinal issues. Every time their daughter, Carolina, ate she threw up. Celeste took her to several doctors in L.A. and they all said that the little girl was fine. The doctors said that the child was spoiled and that she was throwing up for attention. Eventually the doctors explained that they believed the parents needed psychological evaluation because they continued to take their daughter in for testing even after the doctors said that they found nothing pathologically wrong with her. With no solution or diagnoses found in the U.S. Celeste and her husband spoke to Celeste’s brother who was friends with a specialist in Morelia and set up an emergency consultation. Immediately, Celeste and her husband purchased 160 two plane tickets, Mother and daughter arrived in Morelia that same night. They were greeted at the airport by a team of doctors and Carolina was immediately admitted to the hospital where her intestines were found to be hard as a rock and not working properly. The team of doctors agreed that the best remedy would be for them to administer a salve of worms that would eat away at the blockage in Carolina’s intestines; this treatment cost the Cortez Family 2,500 pesos a small amount of money in comparison to all of the doctor visits they had paid for in the U.S. Celeste was assured that the worms would not affect Carolina’s internal organs in a negative way and that the procedure would be relatively quick and painless. Celeste shared, “she was sent home immediately and within hours of the procedure she was eating and digesting food properly”. The doctors in Mexico explained to the Cortez family that the doctors in L.A. had left the case unattended for far too long and that “if the child had gone any longer without treatment she would have died from the toxins in her body”. Celeste and her husband first made use of the available resources in the U.S. for the treatment of their daughter. They actively sought out assistance but passively adhered to the structure of the U.S. health care system which required numerous tests and referrals, all the while their child’s health was deteriorating. Finally Celeste and her husband reclaimed their agency and sought out the assistance of a family member in Mexico, who they trusted to organize the team of doctors that would assess and treat their daughter. This family member served as a proxy agent who contributed to a transnational network of individuals who worked collectively in the best interest of Carolina’s health. In a similar vein, adult immigrants also seek care for themselves in Mexico once they believe they have received all the care they can get in the U.S. or simply if they 161 believe their odds of a diagnoses and treatment may be better in their native Mexico. In essence, a lackluster response in the U.S. regarding a particular health care need has driven some of the individuals in this study to pay for private care in a system that is more familiar to them and more conducive to their immediate health care needs. Unfortunately, this is not a possibility for all of the participants involved in the study as only some have the financial stability and immigration status that permits such international travel. In a study by Horton & Cole (2011) the authors found that Mexican immigrants with U.S. health insurance often chose to return to Mexico for private care because of the difference in distinctive styles between the two systems, hailing how fast services were received, the types of individual attention experienced, effectiveness of prescribed medications and the level of confidentiality in the doctor patient relationship as opposed to the U.S.’s impersonality, system of referrals, uniformity in treatment regimens and high volume of operations. Going to Mexico for care presents both challenges and advantages for the transnational immigrant. Living in the U.S. reduces the likelihood that the immigrant will be covered under any of the Mexican health programs, therefore leaving the immigrant to locate the appropriate private doctors in Mexico for specific services and pay for the services provided with cash. On the other hand, as one immigrant shared, “the waits to see specialists in Mexico are very short”. One is usually seen immediately by the private doctors in Mexico without appointment, as long as you have the money. Another factor contributing to these return visits for Medical care is the immigrant’s ease of comfort with the Mexican medical system, and the immigrant’s level of palanca with specialists and other doctors. After speaking with Victor Marinez, I 162 realized that the general consensus among transnationals was that seeing several doctors in Mexico in order to get proper treatment was a small price to pay if they believed they would get the care they could not receive in the U.S. Victor explained his transnational journey for health care that lasted several months and into several years. When Victor missed his second appoint for kidney stone removal because of a miscommunication between he and his interpreter he was put on a waiting list and left with a catheter in place. To forestall the pain he was given high doses of Vicodin and other narcotics for pain which he believes caused both esophageal damage and stomach damage. Victor grew very upset with the significant delays in treatment. He felt that the catheter was becoming imbedded after more than a year of waiting, so he made the decision to return to his hometown of Orango to seek care. Once in Mexico Victor found the pain to be intolerable, he chose to go to a nearby town, where his doctor of choice has a private practice. The private doctor diagnosed Victor with high blood pressure, gastritis, a throat infection and kidney stones. Unequipped to treat so many ailments he recommended Victor see an acquaintance of his in Morelia. The doctor in Morelia began to treat Victor but then he recommended that he visit a specialist for the kidney stone removal in Guanajuato. Victor was able to get an appointment with the specialist immediately. A surgery was scheduled in the neighboring state of Queretaro, the only state with the specific laser needed to break up the kidney stones. When he was taken to the operating room for the surgery his blood pressure dropped exceedingly low and the surgery was cancelled. He waited 20 additional days with the catheter in place until the doctor believed him to be well enough to undergo 163 surgery. After he passed the stones the catheter was removed. He was then sent home the next day and he recuperated at his small home in Orango. Victor like some of the other participants who return to Mexico for care believes that Mexico is their only option as services are received much faster and efficiently in the private for-profit sector. According to Victor, “It is always much cheaper in Mexico than in the U.S.”. With money and palanca Victor made a choice to no longer be a passive agent waiting in line for the hospital to have room to schedule his kidney stone removal. Both the pain of illness and his previous positive experiences with the Mexican health care system led Victor to put his trust in a network of private doctors in his native Mexico. Navigating health care locally at the community level. All of the examples presented earlier in this chapter reflect the individual, proxy and collective adaptive strategies for accessing various health care options. None of the examples, however demonstrate the immense power with which a transnational collective body can organize in order to help and strategize for an individual and a group of individuals with limited agency. Dry cleaning attendant Juanita Carranza knows first hand what it is like to face a serious health complication with no means for covering the cost. With no where to turn friends spoke on behalf of this woman and advocated for her health needs to a group that had the community manpower to assist in a desperate situation. In June of 2009 Juanita Carranza went to the emergency room for severe stomach pain. She was told she had a stomach infection that had spread to her blood. She was treated and discharged but the pain continued. With only the tarjetita blanca Juanita was put in contact with a bilingual woman who began to fill out Medicaid paperwork in order 164 to assist Juanita with the bills. By September of that year Juanita could no longer endure the pain. She went promptly to the bilingual health clinic where a pap-smear was performed. Juanita was told that she was fine but the 37 year old could not understand why the pain persisted. The clinic doctor recommended that Juanita be seen by Dr. Jones, a private gynecologist, for an ultrasound. Dr. Jones assessed Juanita and told her that she would need a hysterectomy because she had cervical fibroids. That same week, after the ultrasound, Juanita began to hemorrhage. She went immediately to the hospital where doctors stopped the bleeding and told Juanita she needed a biopsy of the uterus. Juanita stayed in the hospital for four days and was then released. During her three week follow up, Juanita was told she had Cancer of the uterus through an impersonal telephone translation service. Juanita grew worried because of her diagnosis and lack of insurance coverage. The doctor informed her that figuring out how she would pay for her care was something that could be determined after a course of treatment was established. The doctor at the hospital sent Juanita for further tests to make sure the Cancer had not metastasized to her lungs. Fortunately the Cancer was localized and she was scheduled for immediate surgery. When Juanita awoke from anesthesia she was surprised to find that the doctors had opened her up and decided not to proceed with the surgery because the Cancer was far too advanced to try and remove her uterus. The doctors stitched her up and told her that a combination of Chemotherapy and Radiation would be the best treatment regimen. Juanita was sent home the next day. At the time of our interview Juanita was waiting to hear from the doctor’s offices to find out when her therapies would begin. Juanita was growing tired of waiting, as they had informed her of the advanced nature of her Cancer. 165 She was told, in the hospital, that her therapies would be scheduled within the next week and at the time of our interview Juanita had already been waiting for almost four weeks. Juanita does not speak English, so during our interview she asked me to call the Radiation Oncology office to find out why there was such a delay. When I was finally able to speak to an actual receptionist she informed me that their office had left a message and were waiting to hear back from Juanita. They did not understand why she had not scheduled her first Chemotherapy session. I asked if they had any staff that spoke Spanish and they said no, I then proceeded to explain that Juanita did not understand the messages because they were in English. In the end, Juanita was scheduled for her Chemotherapy sessions and radiation treatments. Due to the illness, Juanita had to stop working and due to her immigration status she was not eligible to receive disability benefits from her employer. She told me her emergency Medicaid qualification was only going to cover a portion of the bills. Throughout the entire experience Juanita worried about how she would pay for her care. Suffering the physical pain of illness, being treated for the wrong disease and finding out that one has inoperable Cancer can be an overwhelming experience for any single mother. Juanita’s physical pain and diagnosis were accompanied by the emotional strain of not knowing the language or how she would survive financially and not owe the hospitals for such extensive care. During Juanita’s experience with the U.S. health care system she was an active agent making individual choices to seek out care when she felt pain, yet in order to receive treatment she had to also respond passively and filter her agency by proxy through the County Health Plan’s referral system. Juanita, unknowingly, 166 put her faith in the hands of the doctors who essential misdiagnosed her and left her Cancer to grow to an inoperable stage. After speaking with Juanita further she shared that part of the reason she had not been scheduled for chemotherapy or radiation was because the Oncology office was waiting to find out if Medicaid or other government assistance would be covering a portion of the treatments. Ultimately a portion of the bills were covered under emergency Medicaid assistance the rest were left to Juanita who set up a payment plan. When friends in Grovenburg found out about Juanita’s financial situation and obvious sickness, her case was presented to the comité [committee] of San Judas. Initially, Juanita was not aware that Grupo San Judas was planning to help her pay the oncology bills. It was to her surprise they chose to use their Valentines Day kermes as a fundraiser for Juanita and the sick children in Orango. The Hometown Association, consisting of documented and undocumented families from Orango made a collective decision to proceed with a community effort that would benefit a member of the local community. As an individual Juanita was only able to self-react to her situation up to a certain point. Once all avenues for funding her health needs were expended, San Judas formed as Bandura (2006) explains, “a conjoint belief in their collective capability to achieve a given attainment” (p. 165). As group members the collective was sure they could navigate and solve a situation that seemed without solution. Through interdependent efforts the group organized the largest kermes they had ever held with the highest funds raised. When asked why she thought so many people donated time to cook; money to rent the hall; or food items and beverages to sell, Mercedes Perez (the group secretary) explained that, “it was without question the easiest 167 decision the community made because Juanita was one of their own.” She explained that many of the group members are undocumented and they know what it is like to be without insurance. She said that nobody hopes to be in that type of situation, but because of San Judas, group members facing difficult health situations have a reliable network of financial, social and emotional support. Figure 10: Yadira Segovia and others enjoy a kermes held by Grupo San Judas in the hall/gymnasium of San Cristobal Catholic Church in Grovenburg, Michigan similar to the one held for Juanita Carranza Figure 11: Pozole [a spicy pork and chicken soup] prepared for a San Judas kermes in Grovenburg, Michigan Perhaps ones position plays a role in whether or not one is identified as “a person in need of assistance” within the group. During my time working with San Judas decisions about where money would be allocated and for whom, were made by those who 168 were present at open committee meetings. I got the impression that because Juanita is an undocumented, single, unemployed, mother, with an immediate need; she was in a vulnerable position that warranted community involvement. According to Alcoff (1988) the identities we hold in communities are not essential qualities but rather markers of relational positions to our environment and the people that make up our environment. In this vein individual’s palanca in San Judas is determined by their level of involvement in cyclical community efforts. During the Valentines Day Kermes Juanita was the recipient of funds allotted to help her pay her health care bills. At future kermeses and functions of the group, Juanita may attend planning meetings, serve as a cook or choose to donate vegetables or beverages; all of which further solidify her membership in the collective agentive decision making body. Strategizing Agency Locally & Transnationally in Order to Navigate Health Care In an effort to navigate the health care systems of the U.S. and gain access to health care resources, the immigrants in this study made choices as to who they would let contribute to their process of decision making. Given the situational context of their experience these new immigrants strategized and intentionally chose to utilize agency at the individual, proxy and collective levels in order to gain a desired health outcome. In most cases as evidenced in the cases presented throughout this chapter, the majority of immigrants surrender their individual agency to the institutional structures of the U.S. health care system upon arrival. When needs are not met or immigrants are uncomfortable with the types of treatment and information received or lack thereof, they seek out alternative resources through proxy and collective agency. 169 The immigrants in this study utilized their transnational status to create innovative strategies that involved a bidirectional flow of resources, and information necessary for survival in the U.S. Currently there is an increase in safety net health care, in the form of government funded health plans and partial services found at the local level (Becker, 2004). Although, as we have seen, many undocumented depend on this useful form of government funded care they are often unable to fully understand or access the resources in this health system. In addition, as health care reform takes shape and undocumented immigrants are excluded from certain policy the daily impacts will be felt as access to certain resources are denied. The effects of one such policy, The Combat Methamphetamine Act 2005, which was intended to protect the well being of the nation by limiting the possibility of methamphetamine production, have hit home especially with the undocumented. New legal requirements include: documentation of those purchasing pseudoephedrine, ephedrine, and phenylpropanolamine for three years, purchasers must present state issued I.D. and they are only allowed to purchase a certain amount per month. These requirements, though seemingly appropriate in combating the growth of underground meth labs, have indirectly contributed to several negative outcomes for the undocumented. Almost no undocumented immigrant possesses a license or state issued I.D. because of policy requiring those applying for a license to have a valid social security number, something this population lacks. In addition undocumented individuals live in the shadows trying vehemently to avoid documentation, a specific requirement in this law. These individuals, many of whom do not have formal insurance and who utilize pharmacies as a primary source of self care, are unable to access over counter medication 170 specifically designed to treat sinus and nasal congestion. Such laws increase health risk for an already structurally vulnerable population, leaving them in a position where they may be more likely to self deport in order to gain access to primary health resources. A lack of language competency, lack of transportation, lack of knowledge about the institutional structures, lack of documentation, a lack of trust, and a lack of inclusion in policy have led individuals to seek out available alternative resources for care both locally and transnationally utilizing palanca and agency at all three levels. 171 Chapter 7: The Deportation Center, What this all Means for Families across Borders The detention center was cold when I walked in holding the little girl’s hand. I had no idea what to expect, I had never been inside a jail. I had driven over two hours, that crisp Saturday in October, to take Fernando Segovia’s two young daughters, Seferina 10 and Belinda 8 to bid farewell to their father who had been detained by ICE two days prior. Fernando’s wife Yadira wanted very badly to see her husband, but due to her undocumented status she surely would have been detained upon setting foot in the jail for visitation. When we arrived I was notified that only two individuals would be allowed in to see Fernando and that the girls could not go into the room without an adult. Immediately, I had to make a decision as to which of the two girls I was going to take in with me. I was torn, how does one choose? Both girls wanted very badly to say good bye to their father and both were too young to fully understand immigration law and the rules involved in the detention process. Eventually I asked Seferina, the eldest, if she wanted to see her father. Belinda the younger of the two stayed in the waiting area. Seferina and I entered and sat down at the only open telephone. Fernando was quickly brought in and sat down behind the plexi-glass window facing the two of us. Fernando and I picked up the phones at the same time. He looked weak, worried and tired. He was coughing and explained that he had developed a cold since his arrival in the jail. I asked him if he had experienced any problems and he said that he had not taken his blood pressure medication since being detained. I asked him if he had requested the medications from the corrections officers and he said, “I didn’t know I was allowed to ask for such things”. I knew our time was short and that Fernando would soon be taken away. So I quickly handed the phone to Seferina in order to speak with her father. Fernando tried to remain strong giving his little girl instructions. He told her to listen to her mother, do well in school, stay out of problems and most of all, he told little Seferina not to worry that she needed to be strong so that she could help with her younger sister and baby brother. In that moment Seferina was not only saying goodbye to her father but was also charged with responsibilities as the eldest child that she had never had before. The severity of how her family structure was unraveling around her was apparent as the conversation came to a close and Seferina began to shake with worry and sadness. In Fernando I saw a man at his most desperate state. As he said good bye to his daughter I withstood the urge to cry and felt their pain as both father and daughter cried in unison. Fernando didn’t tell his little girl to stop, instead his face looked like a mirror reflection of little Seferina through that plexi-glass window. I knew that what this family was facing, the pain, anguish, separation and emotional stress would leave lasting scars. I knew in that moment that politicians and bureaucrats who created such laws that demanded the deportation of “illegal aliens” did not comprehend the weight of such forms of governmentality on actual U.S. citizens, the children of the undocumented. I stood and supported this family knowing full well that I could do nothing to remedy the heartbreak they faced. Before leaving I asked Fernando what he was planning to do and he said that he had no choice, he must return to Mexico but that he knew that he would not be there long. As he said this he smiled at his little girl and I knew that Fernando would cross many borders, many times in order to return to his family. 172 Fernando, like many other undocumented individuals living in the U.S. have a deep connection to family and community on both sides of the border. They are committed to helping their loved ones who return to or stay in Mexico, through financial support and material goods, while at the same time supporting their family living with them in the United States. In this dissertation I have examined some of the ways in which transnational individuals make certain decisions regarding health and well being, on either side of the border, as a lens for understanding the micro-level human impacts of various forms of governmentality. Since the start of this study, health care policy in the United States has undergone several dramatic changes. Policy related to the Affordable Health Care Act 2010, for example, is being implemented as these lines are being written. How these changes will directly affect the low-income, Hispanic and especially undocumented populations, living in the U.S., is yet to be fully determined. We do know, however that one of the most structurally vulnerable populations, the undocumented, are expressly banned from accessing health coverage through the Affordable health Care Act of 2010, “reaffirming their exclusion from public services and basic legal rights” (Quesada, et al, 2011, p.340). Since before the start of this study debates regarding immigration reform and negative perceptions of Latinos as a drain to U.S. society have ebbed and flowed depending on the economy, certain political platforms, wars and the expansion of particular government offices, such as the Office of Homeland Security (Chavez, 2008; Cornelius, 2002). Certain laws such as the Deferred Action for Childhood Arrivals (DACA) permits the children of undocumented immigrants, who arrived unlawfully before the age of 16 to obtain work visas, temporary resident status and social security 173 numbers however these children are excluded from receiving federal funds such as Federal Financial Aide for higher education. These children are left with little or no funding for University education. Many find work in low skill jobs, further confining a section of the recent immigrant population to low wage earnings and an almost impossible chance for career or educational advancement. As the U.S. moves forward with implementing health care policies and immigration policies that exclude an especially vulnerable population from fully receiving what many may consider basic human rights, we must consider the long term effects of such exclusions on this generation and generations to come. The current crisis along the Mexico-U.S. border, where over 50,000 Central American children are being held in deportation centers after having left countries that lack the infrastructure to handle drug and gang violence on the national level, serves as a lesson that our current immigration situation and policies must be reassessed. While children await decisions, made by U.S. judges, as to whether or not they will remain in the U.S or be deported back to their home countries, the country is witnessing an immigration situation escalate into a humanitarian issue at our front door. Though sensationalized in the media, this immediate crisis, demonstrates how unresolved institutional policies can have life or death consequences on those most structurally vulnerable, in this case children. As I began this dissertation I set out to shed light on the adaptive health management strategies used by a group of transnational Mexican immigrants who live in Michigan and their family members in Michoacan. I took considered individual, social and macro-level institutional barriers to care. I examined the health experiences of people 174 while living in Mexico, as they crossed the border and as they incorporated themselves into U.S. society, focusing on how forms of governmentality at the macro-level have an effect on the daily lives and choices of individuals. Throughout this dissertation I have presented various policies implemented historically which, although not directly designed to have a devastating impact on individual lives, often do have such an effect on the existence of Mexican immigrants. The agentive choices made and adaptive health strategies utilized by these transnational immigrants and their family members, both in the U.S. and in Mexico tell us a great deal about globalization, migration and governmentality. We are able to see through lived experiences how policies used to control the movement of goods and people have a lasting effect in daily experience. As I discussed in Chapter 2, the hostile nature of Mexico-U.S. relations has created a political landscape that limits choices, encouraging individuals and whole communities to take clandestine actions to influence the nature of their lives, regarding both immigration and health care. Conclusions: What we have Learned about how these Individuals Manage Health In following the journeys of the individuals, families and communities in the preceding chapters we have come to see the variability with which people make sense of and navigate both the culture of migration and the culture of health care across transnational borders. People like Fernando and Yadira Segovia and their cyclical experiences bifurcating national boundaries, while being faced with difficulties in accessing health care, give voice to the often silenced lived experiences of over 12 million undocumented immigrants living in the United States. Their journey is one that 175 never truly ends, crossing and re-crossing an extensive set of boundaries and states of liminality in order to manage their health and survive. Agentive strategies. Forms of governmentality are forms of government that no longer seek to manage territories but rather are designed to manage the well being of “the people”. The stories I have presented in Chapters 4, 5, and 6 illustrate how these macro-level forces are felt in institutional policies that are entrenched in society and constrain or guide the agentive decision-making processes of individuals. Throughout this dissertation I have argued that in order to live out their lives and navigate the effects of macro-level institutional reforms individuals and the communities they depend on are driven to make decisions adapting their agency in meaningful ways at multiple levels in order to manage their health. The strategies used by this group of transnational immigrants demonstrate how agency can have multiple forms and how agentive choices can shift as each situation develops. In Chapter 2 I introduced Bandura’s three levels or modes of agency: the personal/individual, proxy/family and collective/community levels, which I’ve used to consider the range of strategies the immigrants I studied used in their everyday lives to meet their needs and reach their various goals(). Given the context of each situation and their capacity to react, immigrants attempt to approach how they will navigate the system differently, as either passive or active agents. When faced with various forms of governmentality individuals make active choices to utilize individual agency making personal decision for personal well-being or in cases where another agent may have more social power or social capital individuals may utilize their proxy agency and surrender their agency temporarily, as we saw in the case of undocumented immigrants who 176 surrendered their agency to coyotes in order to survive the harsh terrain of the desert. In other cases needs and goals can more easily be achieved through communal efforts where multiple resources and knowledge are combined for a common or communally established good, as we saw in the multiple transnational efforts of hometown association San Judas. Generally speaking, when faced with barriers in accessing care or achieving a desired outcome the immigrants in this study actively built necessary structures using networks and resources they have the most experience utilizing, i.e their friends, Tiendas Mexicanas, pharmacies, private doctors, the health system and medical providers in their native Mexico, etc. In rare instances where the individual was incapable of making an agentic choice due to age, illness, gender and/or status, those around them generally stepped in and made choices on their behalf. Cultural citizens. Due to the “legal production of immigrant ‘illegality’” (DeGenova, 2002) undocumented immigrants are left with limited access to public health resources while facing the spectrum of deportation looming on a daily basis. These individuals, their families and communities develop innovative ways to navigate such limitations. During this process these immigrants solidify their experiences as transnational cultural citizens. Their sustained contact with family members living in Mexico, who face a whole different set of challenges in accessing care, contributes to a reciprocal relationship necessary for this particular migration system to function. This reciprocal relationship sustained through extensive networks and a Hometown association allows individuals on both sides of the border access to innovative resources, a cultural identity that has worth on either side of the border, and a support system that transcends physical boundary. Moreover, the journey does not stop with these 177 transnational immigrants, as their children grow and acculturate in U.S. society they too will have to make sense of macro-level policy that affects their daily lives and navigate as their parents do, as cultural citizens. The actions of these transnational immigrants and their family members represent a conflicting duality steeped in the theoretical concept of cultural citizenship. In the case of the immigrants who participated in this study, they actively sought out resources and representation in American society and Mexican society, navigating the health care systems through informal cadenas [chain] of resources and sustained palanca[leverage]in order to acquire the same level of care as other citizens in either or both communities. They would often tap into public resources that are available to the underserved in the U.S. or pay out of pocket for private care in order to be accepted by mainstream society and reap the rewards of such membership by gaining access to health resources. At the same time, they actively made use of their transnational identity, maintaining ties to their hometown and hometown networks as a means for accessing health care that was may not have been accessible to them in the U.S. By tapping into both sets of resources these transnational immigrants were both acknowledging their uniqueness and creating a space/voice for themselves among the mainstream. Proactive agents. The process of physically emigrating from Mexico into the U.S. is a difficult journey physically, financially, and emotionally. In many cases Mexicans living in rural communities are left with little agency in deciding whether or not to emigrate out. International agreements such as NAFTA which introduced low price crops, meats, and goods to the Mexican market created a large rural population with no employment due to the competing U.S. market. The decision to leave Mexico and 178 migrate north has at times been constrained and encouraged by such macro forces controlling markets, economies and infrastructure. As I discussed in Chapter 3, deforestation laws in the areas surrounding Orango had a large impact on the local economy at a time when the country was facing an economic crisis, such reforms left people in Orango, many of whom had family members who had already immigrated to the U.S. as Braceros, with few alternatives but to venture north. Decisions and strategies about well-being and health throughout the migratory journey, from one country into another, are made at multiple agentive levels. People are put in life or death situations that cause them to reassess and reconfigure their agency throughout the crossing due to the hostile environment and stringent policies in place along the border. In many of the cases I came across in this study, people were constrained in their decision-making process due to institutional reforms such as the Secure Border Initiative of 2005 which has pushed immigrants into the harsh terrain of the desert, while crossing the border. The only remaining places where crossing is possible present great risk of illness, injury, and death; due to hypothermia, exposure, and dehydration (Whitaker, 2009). For many of the immigrants I spoke with, the only way they could survive such inhospitable conditions was to surrender their agency to those with more structural power. Those insufficiently equipped to face the perils of crossing, due to age, health, and inexperience depend on those who are stronger, such as other immigrants, or those with more social capital, such as coyotes, to assist them. Health seeking strategies. Even though most of the immigrants I spoke with mentioned several challenges in accessing care, I did not come across anybody who delayed care. On the contrary, participants I spoke with in Orango mentioned how, when 179 left with little resources or immediate social support, they used agency in the form of palanca, a type of social capital rooted in social relations and connections, to secure goals and resources for themselves and their families. These social connections extend to include family members living in the U.S. with more financial capital, the migrant Hometown Association in Grovenburg with social stability and health officials and politicians in Mexico with both social and economic capital In the U.S. several of the undocumented participants mentioned that they did not like going to emergency rooms because they did not want to accumulate high bills or “owe” hospitals for services rendered, because they wanted to maintain “clean records”. In most cases the immigrants I spoke with preferred to pay out of pocket for care as this was something they were accustomed to doing in order to receive fast, quality healthcare in their rural hometown of Orango. They traveled long distances in order to be treated by Latino doctors they had heard positive things about or had already had positive interactions with. Most immigrants who have lived in Grovenburg mentioned how they had to actively seek out resources that were generally filtered to them through informal chains of information. Upon first arriving to their new U.S. environment many participants attended to their health needs by using products and home remedies sold at Mexican stores and pharmacies. They depended on proxies or other immigrants and family members with more knowledge about health resource availability to translate in pharmacies and share information on local public resources. In cases where the immigrants had access to international travel they returned to Mexico and sought out care, services and treatment. In an effort to be proactive about their health when faced with a strange new medical 180 culture, several of the immigrants mentioned actively maintaining contact with physicians in Mexico who would conduct consultations over the phone and prescribe medication, which would then be sent with traveling family or other medical professionals. Most importantly, the entire community used collective agency to actively seek out resources for those most in need of health care assistance through the integration of Kermeses, which served as a form of collective fundraising and way to maintain cultural connections with their sending community. Where to go from Here? For immigrants traveling from one country to another, challenges along the journey are common. But for Mexican immigrants, whose country of origin and new country of destination share a border and a long political history, the journey may be especially challenging. Due to unresolved immigration form crossing the border as undocumented immigrants for instance, produces unsafe conditions that can lead to poor health outcomes. Throughout this dissertation I have provided examples of poor health outcomes due to undocumented migration evident through the experiences of Jesus Granada, Antonieta Rangel, Patricia Suarez, Victor Marinez and others. Considering the position of those who leave Mexico, their reasons for leaving, what they are searching for as they traverse boundaries and how they strategically use agency to challenge institutions of governmentality, may open the door to reforms and policies that truly do take into consideration the well being of the whole population not just those the government deems rightful citizens. Given the current health care restructuring and debates surrounding immigration reform this research is timely in drawing attention to the strategies used for identifying 181 and addressing the health care needs of recent Mexican immigrants. Ethnographic studies, like this one that take into consideration migratory patterns and how macro level reforms impact individual lives, yield significant information about a relatively unacknowledged interconnected population. These insights may inform policy makers as they devise new ways to address health care and immigration issues. Moreover, this study sheds light on areas for improvement at the local level in any setting where the Latino population and presence has increased. As politicians gear up for a new presidential election, stances on immigration reform as well as opinions regarding how the Affordable Healthcare Act has been received and implemented are sure to bring attention to those living in the shadows of America. Although, as I have presented throughout the dissertation, transnational immigrants are innovative strategic agents in countering hegemonic practices of governmentality, the existence of a hostile environment, as evidenced in exclusionary reforms, only serves to contain Latino immigrants within a structurally vulnerable state. Socio-economic status, immigration status, limited English proficiency, federal and local policies on access to publically funded health care, residential location and stigma and marginalization all contribute to making immigrants a “vulnerable population” or a group at increased risk of poor health outcomes and inadequate health care (Derose, Escarce & Lurie, 2007). It may be to everyone’s advantage to allow the undocumented to become citizens, pay taxes and qualify for proper health insurance that covers routine checkups and doctor visits. This would then lead them to be proactive in managing their healthcare, leading to less emergency room visits and more preventative exams, which can detect expensive chronic conditions. 182 As described throughout this dissertation, globalization is a process that has allowed for the consistent flow of goods, capital, knowledge, culture, technology and people across the globe. In order to manage the movement of commodities and people, governments developed plans/policies at the macro-level which are aimed at protecting the best interest of the people. Unfortunately such policies and institutional reforms can loose touch with the people they directly and indirectly affect. Throughout these chapters I have shared the stories of people from one transnational community who proved that even with limitations and barriers to care they were able to creatively strategize and adapt. These transnational immigrants strategized by interweaving their agentive practices. They utilize not only individual agency but family and community agency also, in order to seek and achieve the goals and resources necessary for survival across the border. Their cyclical migratory experiences while dealing with the challenges of health care in Mexico, while crossing the U.S.-Mexico border, and while living in the U.S. are a testament to how people challenge adverse situations with limited resources. The experiences of these immigrants also contribute to a clearer understanding of how very important transnational lives are to managing health issues across borders. 183 REFERENCES 184 REFERENCES Acuña, R. (2007). Occupied America: A history of Chicanos (6th ed). New York, NY: Longman. Ackelson, J. (2005). Constructing security of the US–Mexico border. Political Geography, 24 (2), 165–184. Adler-Hellman, J. (2008). The world of Mexican migrants. New York, NY: The New Press. Ahearn, L. M. (2001). Language and agency. Annual review of anthropology, 30, 109137. Alcoff, L. (1988). Cultural feminism versus post-structuralism: The identity crisis in feminist theory. Signs, 13(3), 405-436. Amin, S. (1974). Accumulation on a world scale. New York, NY: Monthly Review Press. Andreas, P. (2012). Border games: Policing the US-Mexico divide. Ithaca, NY:Cornell University Press. Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (2000). Exercise of human agency through collective efficacy. Current Directions in Psychological Science, 9(3), 75-78. Bandura, A. (2006). Toward a psychology of human agency. Perspectives on Psychological Science, 1(2), 164-180. Bastida, E., Brown, S., & Pagan, J. (2008). Persistent disparities in the use of health care along the US-Mexico border: An ecological perspective. American Journal of Public Health, 98,1987-1995. Batalova, J. (2008). Mexicans immigrants in the United States. Retrieved from http://www.migrationpolicy.org/article/mexican-immigrants-united-states-1/ Becker, G. (2004). Deadly inequality in the health care "safety net": Uninsured ethnic minorities' struggle to live with life-threatening illnesses. Medical Anthropology Quarterly.18 (2), 258-275. Becker, G. (2007). The uninsured and the politics of containment in the US. Medical Anthropology: Cross-Cultural Studies in Health and Illness, 26 (4), 299-321. 185 Bennett, J. W. (1996). Applied and action anthropology: Ideological and conceptual aspects. Current Anthropology, S23-S53. Berreman, G. D. (1968). Is anthropology alive? Social responsibility in social anthropology. Current Anthropology, 9(5), 391-396. Bogardus, E. S. (1919). Essentials of americanization. Los Angeles, CA: University of Southern California Press. Borjas, G.J. (1989). Economic theories and international migration. International Migration Review Special Silver Anniversary Issue. 23(3), 457-485. Brettell, C. B. & Hollifield, J.F. (2000). Migration Theory: Talking Across Disciplines. In C.B. Brettell & J.F. Hollifield. (Eds.), Migration theory (pp. 1-26), New York, NY: Routledge. Brick, K., Challinor, A. E., & Rosenblum, M. R. (2011). Mexican and Central American immigrants in the United States. Washington, DC: Migration Policy Institute, June. http://www. migrationpolicy. org/pubs/MexCentAmimmigrants. pdf. Brower, L. P., Castilleja, G., Peralta, A., Lopez-Garcia, J., Bojorquez-Tapia, L., Diaz, S., Melgarejo & Missrie, M. (2002). Quantitative changes in forest quality in a principal overwintering area of the monarch butterfly in Mexico, 1971–1999. Conservation Biology, 16(2), 346-359. Buckser, A. (2009). Institutions, agency, and illness in the making of Tourette Syndrome. Human Organization, 68(3), 293-306. Carillo, J.E., Trevino, F.M., Betancourt, J.R., & Coustasse, A. (2001). Latino access to health care: The role of insurance, managed care, and institutional barriers. M. Aguirre-Molina, & C.W. Molina, R.E. Zambrana (eds.), In Health Issues in the Latino Community (pp 55-73). San Francisco, CA: Jossey-Bass. Castles, S. & Miller, M. (2009). The age of migration: International population movements in the modern world (4th ed.). New York, NY: The Guilford Press. CERD Working Group on Health and Environmental Health. (2008). Unequal health outcomes in the United States. Retrieved from http://www.prrac.org/pdf/CERDhealthEnvironmentReport.pdf Chavez, L., Flores, E., & Lopez-Garza, M. (1992). Undocumented Latin American immigrants and U. S. health services: an approach to a political economy of utilization. Medical Anthropology Quarterly. 6(1). 6-26. Chavez, L. (2008). The Latino threat: Constructing immigrants, citizens, and the nation. Stanford, CA: Stanford University Press. 186 Coffman, M. J., Shobe, M. A., & O'Connell, B. (2008). Self-prescription practices in recent Latino immigrants. Public Health Nursing, 25(3), 203-211. Collier, S.J., & Ong, A. (2005). Global assemblages, anthropological problems. In S.J. Collier and A. Ong (Eds.), Global assemblages: Technology, politics, and ethics as anthropological problems (pp.3-21). Malden, MA: Blackwell Publishing. Cordova, E. (2013). After brutal summer heat, border-crosser deaths up this year over 2012. Cronkite News. http://cronkitenewsonline.com/2013/09/after-brutalsummer-heat-border-crosser-deaths-up-this-year-over-2012/ Cornelius, W. A. (2002). Ambivalent Reception. In M.M. Suarez-Orozco (Eds.), Latinos: Remaking America, (pp.165-89). Oakland,CA: University of California Press Creswell, J. W., Hanson, W. E., Plano, V. L. C., & Morales, A. (2007). Qualitative research designs selection and implementation. The Counseling Psychologist, 35(2), 236-264. Cunningham, P., Banker, M., Artiga, S., & Tolbert, J. (2006, September 1). Health coverage and access to care for hispanics in "new growth communities" and "major hispanic centers”. Retrieved from http://www.kff.org/uninsured/upload/7551.pdf Cunningham, L., Lester, S., & O'Reilly, D. (Eds.). (2013). Developing the capable practitioner: Professional capability through higher education. London, U.K.: Routledge. Cunningham, P., McKenzie, K., & Taylor, E. F. (2006). The struggle to provide community-based care to low-income people with serious mental illnesses. Health Affairs, 25(3), 694-705. Dallmayr, F. (1998). Alternative visions: Paths in the global village. Lanham, MD: Rowman & Littlefield Dean, M. (2010). Governmentality: Power and rule in modern society. London,UK: Sage publications. De Genova, N. P. (2002). Migrant" illegality" and deportability in everyday life. Annual Review of Anthropology, 31, 419-447. DeNavas-Walt, C., Proctor, B. & Smith, J. (2007). Income, poverty and health insurance coverage in the United States 2006. Report Number: P60-233 Derose, K. P., Escarce, J. J., & Lurie, N. (2007). Immigrants and health care: Sources of vulnerability. Health Affairs, 26(5), 1258-1268. Di Chiro, G. (2004). "Living is for everyone": Border crossings for community, 187 environment, and health. Osiris, 19, 112-129. Dukes, S. (1984). Phenomenological methodology in the human sciences. Journal of Religion and Health, 23(3), 197-203. Ericson, A. S. (1970). An analysis of Mexico's border industrialization program. Monthly Labor Review, 33-40. Eschbach, K., Hagan, J., & Rodriguez, N. (2003). Deaths during undocumented migration: Trends and policy implications in the new era of homeland security. In Defense of the Alien, 26, 37-52. Families USA. (2014). http://familiesusa.org/issues/medicaid Fawcett, J. T., & Arnold, F. (1987). 19: Explaining diversity: Asian and pacific immigration systems. Center for Migration Studies special issues, 5(3), 453-473. Fernández-Kelly, P., & Massey, D. S. (2007). Borders for whom? The role of NAFTA in Mexico-US migration. The ANNALS of the American academy of political and social science, 610(1), 98-118. Flores, W. V., & Benmayor, R. (Eds.). (1997). Latino cultural citizenship: Claiming identity, space, and rights. Boston, MA: Beacon Press. Foucault, M. (1991). Orders of discourse (1971).Reprinted in S.Lash (Ed.) PostStructuralist and Post-Modernist Sociology. Aldershot: Edward Elgar. Foucault, M., Burchell, G., Gordon, C., & Miller, P. (Eds.). (1991). The Foucault effect: Studies in governmentality. Chicago, Ill:University of Chicago Press. Friebel, G., & Guriev, S. (2006). Smuggling Humans: A theory of debt-financed Migration. Journal of the European Economic Association, 4(6), 1085-1111. Frenk, J., Gonzalez-Pier, E., Gomez-Dantes, O., Lezana, M.A., Knaul, F. (2006). Comprehensive reform to improve health system performance in Mexico. Lancet. 368 (9546), 1524-1534. Frøkjær, B., Bolvig, T., Griese, N., Herborg, H., & Rossing, C. (2012). Prevalence of drug-related problems in self-medication in Danish community pharmacies. Innov. Pharm. 3(95),1-10. Fussell, E., & Massey, D. S. (2004). The limits to cumulative causation: International migration from Mexican urban areas. Demography, 41(1), 151-171. Galtung, J. (1975). Essays in peace research (Vol. 1). Copenhagen: Ejlers. Gamio, M. (1969). Mexican immigration to the United States. New York, NY: Arno 188 Press. García y Griego, M., & Campos, M. V. (1998). Colaboración sin concordancia: La Migración en la nueva agenda bilateral México-Estados Unidos. Nueva agenda bilateral in la relación México-Estados Unidos. M. Verea, R. Fernández de Castro, and S. Weintraub (cords.). México: Fondo de Cultura Económica, 107134. González Baker, S., Bean, F. D., Latapi, A. E., & Weintraub, S. (1998). US immigration policies and trends: The growing importance of migration from Mexico. In M.M. Suarez-Orozco (ed.), Crossings: Mexican immigration in interdisciplinary perspectives, (pp.79-105). Cambridge, MA:Harvard University, David Rockafeller Center for Latin American Studies. Gordillo, L.M. (2010). Mexican women and the other side of migration: engendering transnational ties. Austin, TX: The University of Texas Press. Graham, R. E., Ahn, A. C., Davis, R. B., O'Connor, B. B., Eisenberg, D. M., & Phillips, R. S. (2005). Use of complementary and alternative medical therapies among racial and ethnic minority adults: Results from the 2002 national health interview survey. Journal of the National Medical Association, 97(4), 535. Grigg, D. B. (1977). EG Ravenstein and the “laws of migration”. Journal of Historical geography, 3(1), 41-54. Guarnizo, L. E., & Smith, M. P. (1998). The locations of transnationalism. Transnationalism from below, 6, 3-34. Guendelman, S., & Jasis, M. (1990). Measuring Tijuana residents' choice of Mexican or U.S. health care services. Public Health Reports, 105(6), 575-583. Hanson, G. H., & McIntosh, C. (2010). The great Mexican emigration. The Review of Economics and Statistics, 92(4), 798-810. Held, D., McGrew, A., Goldblatt, D., & Perraton, J. (1999). Global transformations: Politics, economics, and culture. Stanford, CA: Stanford University Press. Hobbs, A. W., & Jameson, K. P. (2012). Measuring the effect of bi-directional migration remittances on poverty and inequality in Nicaragua. Applied Economics, 44(19), 2451-2460. Hondagneu-Sotelo, P. (1994). Gendered transitions: Mexican experiences of immigration. Oakland, CA:University of California Press. Hondagneu-Sotelo, P. (Ed.). (2003). Gender and US immigration: Contemporary trends. San Diego, CA: Univ of California Press. 189 Horton, S., & Cole, S. (2011). Medical returns: seeking health care in Mexico. Social Science & Medicine, 72(11), 1846-1852. Hunt, L. M., & Montemayor, I. (2010). Health care needs in crisis: An exploratory study of Latinos in the Midwest. Practicing Anthropology, 32(1), 9-14. Huntington, S. P. (2004). Who are we?: The challenges to America's national identity. New York, NY:Simon and Schuster. Kaiser, M. (2001). The People Smugglers. Transition, 90, 30-41. Keogan, K. (2002). A sense of place: The politics of immigration and the symbolic construction of identity in southern California and the New York metropolitan area. Sociological Forum (17), 2, 223-253. Kolcaba, R. (1997). The primary holisms in nursing. Journal of advanced nursing, 25(2), 290-296. Lakin, J. (2009). Mexico’s health system: More comprehensive reform needed. PLoS Medicine, 6(8), 1-3. Lamphere, L. (2004). The convergence of applied, practicing, and public anthropology in the 21st century. Human Organization, 63(4), 431-443. Li, T. M. (2007). The will to improve: Governmentality, development, and the practice of politics. Durham, NC: Duke University Press. Lin, N. (2002). Social capital: a theory of social structure and action (structural analysis in the social sciences). Cambridge,U.K.:Cambridge University Press Low, S. M., & Merry, S. E. (2010). Engaged anthropology: diversity and dilemmas. Current Anthropology, 51(S2), S203-S226. Martínez, J. N. (2007). Globalization and its Impact on Migration in Agricultural Communities in Mexico. San Diego, CA:University of California Press. Massey, D. S., & Liang, Z. (1989). The long-term consequences of a temporary worker program: The US bracero experience. Population Research and Policy Review, 8(3), 199-226. Massey, D. S., Arango, J., Hugo, G., Kouaouci, A., Pellegrino, A., & Taylor, J. E. (1993). Theories of international migration: a review and appraisal. Population and development review, 19, 431-466. Massey, D. S., Durand, J., & Malone, N. J. (2002). Beyond smoke and mirrors. New York, NY: Russell Sage Foundation. 190 Massey, D. S., & Sánchez, M. (2010). Brokered boundaries: Immigrant identity in antiimmigrant times. New York, NY: Russell Sage Foundation. Mendoza, C. (2006). Transnational spaces through local places: Mexican immigrants in Albuquerque (New Mexico). Journal of Anthropological Research, 62(4), 539561. Meneses, G. A. (2003). Human rights and undocumented migration along the MexicanUS border. UCLA L. Rev., 51, 267. Munck, R. (2008). Globalisation, governance and migration: an introduction. Third World Quarterly, 29(7), 1227-1246. Ngai, M. M. (2005). Impossible subjects: Illegal aliens and the making of modern America. Princeton University Press. Ngai, M. M. (2010). “A nation of immigrants”: The cold war and civil rights origins of illegal immigration. Occasional Paper, 38. Ong, A. (1996). Cultural citizenship as subject-making: immigrants negotiate racial and cultural boundaries in the United States. Current anthropology,(37) 5, 737-762. O’Reilly, D., Cunningham, L., & Lester, S. (1999). Developing the capable practitioner. VA: Stylus Publishing. Orozco, M. (2000). Latino hometown associations as agents of development in Latin America. Report prepared for Tomás Rivera Policy Institute (TRPI) and Inter-American Dialogue (IAD). Washington, D.C. Ortiz, R. (2006). Mundialization/globalization. Theory, Culture, and Society, 23, 401-403 doi: 10.1177/026327640602300270 Parra, C.R., Bulock, R.L., Imig, D., Villarruel, F., & Gold, S. (2006). Trabajando duro todos los días: Learning from the life experience of Mexican-origin migrants families. Family Relations, 55, 361-375. Portes, A., & Böröcz, J. (1989). Contemporary immigration: theoretical perspectives on its determinants and modes of incorporation. International migration review, 606630. Portes, A., Escobar, C., & Radford, A.W. (2007). Immigrant transnational organizations: A comparative study. International Migration Review. 41(1), 242281. 191 Portes, A., Guarnizo, L.E., & Landolt, P. (1999). The study of transnationalism: Pitfalls and promise of an emergent research field. Ethnic and racial studies. 22(2), 217-237. Potter, B. (2003). Alliances and agreements. In Mexico and the United States. Stacy, L. (ed.), Tarrytown, NY: Marshall Cavendish Corporation, pp 40-43. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Retrieved from http://www.who.int/about/definition/en/print.html Pylypa, J. (2001). Latino immigrants: Self-medication practices in two California Mexican communities. Journal of Immigrant Health, 3(2), 59-75. Quesada, J., Hart, L. K., & Bourgois, P. (2011). Structural vulnerability and health: Latino migrant laborers in the United States. Medical anthropology. 30(4), 339362. Reisler, M. (2001). Always the laborer, never the citizen: Anglo perceptions of Mexican immigrants during the 1920s. In D. G. Gutierrez(ed), Between two worlds:Mexican immigrants in the United States. (4th ed), (pp. 23-44) Jaguar Books on Latin America. Wilmington, VA: Scholarly Books Inc. Rempell, L. (2005). Leveraging migrant remittances to Mexico: The role for sub-national government. Journal for Development and Social Transformation, 69-78. “Reserva Especial de la Biosfera Mariposa Monarca". Secretaria de Medio Ambiente, Recursos Naturales y Pesca, Instituto Nacional de Ecologia, Comision Nacional para el Conocimiento y Uso de la Biodiversidad. November 15, 2007. Rivera, J. O., Ortiz, M., Lawson, M. E., & Verma, K. M. (2002). Evaluation of the use of complementary and alternative medicine in the largest United States-Mexico border city. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 22(2), 256-264. Rodríguez, N. (1996). Social construction of the US-Mexico border (Vol. 96). Center for Immigration Research, University of Houston, College of Social Sciences. Rosaldo, R. (1994). Cultural citizenship and educational democracy. Cultural anthropology, 9(3), 402-411. Rosenblum, M. R., & Brick, K. (2011). US immigration policy and Mexican/Central American migration flows: Then and now. Washington, DC: Migration Policy Institute and Woodrow Wilson International Center for Scholars, August. http://www. migrationpolicy. org/pubs/RMSG-regionalflows. pdf. 192 Rovin, K., Stone, R., Gordon, L., Boffi, E., & Hunt, L. (2012). Better Than Nothing: Participant Experiences in Using a County Health Plan. Practicing Anthropology, 34(4), 13-18. Ruiz-Beltran, M., & Kamau, J. K. (2001). The socio-economic and cultural impediments to well-being along the US-Mexico border. Journal of community health, 26(2), 123-132. Savitri, G.G. (1974). Internal migration into the Bangkok metropolitan area. Pittsburg, PA: University of Pittsburgh. Scheuerman, W.E. (2004). Liberal democracy and the social acceleration of time. Baltimore, MD: Johns Hopkins Press. Scheper-Hughes, N. (2009). Making anthropology public. Anthropology Today, 25(4), 1-3. Schiller, N.G., Basch, L. & Blanc-Szanton, C. (1992), Transnationalism: A New analytic framework for understanding migration. Annals of the New York Academy of Sciences, 645, 1–24. doi: 10.1111/j.1749-6632.1992.tb33484.x Shrestha, Nanda.(1987). Institutional policies and migration behavior. World Development. 15(3), 329-345. Schuck, P. (2000). Law and the Study of Migration. In C.B. Brettell, & J.F. Hollifield, (eds.) Migration Theory (pp.187-204). New York, NY: Routledge. Stephen, L. (2007). Transborder lives: Indigenous Oaxacans in Mexico, California, and Oregon. Durham, NC: Duke University Press. Stryker, S., & Burke, P. J. (2000). The past, present, and future of an identity theory. Social Psychology Quarterly, 63(4), 284-297. Trangmar, P., & Diaz, V. A. (2008). Investigating complementary and alternative medicine use in a Spanish-speaking Hispanic community in South Carolina. The Annals of Family Medicine, 6(suppl 1), S12-S15. Turner, A. N., Ellertson, C., Thomas, S., & García, S. (2003). Diagnosis and treatment of presumed STIs at Mexican pharmacies: Survey results from a random sample of Mexico City pharmacy attendants. Sexually Transmitted Infections, 79(3), 224228. Turner, V. (1987). Betwixt and between: Patterns of masculine and feminine initiation, Peru, Ill:Open Court Publishing. 193 Tomlinson, J. (1999). Globalization and culture. Chicago, Ill: University of Chicago Press. Ugalde, A. (1985). Ideological dimensions of community participation in Latin American health programs. Social Science & Medicine, 21(1), 41-53. Urrea, L. A. (2008). The devil's highway: A true story. Urrea, L. A. (2008). New York, NY: Hachette Digital, Inc. U. S. Census Bureau. (2012). U.S. Census Bureau: State and County Quick Facts. Data derived from Population Estimates, American Community Survey, Census of Population and Housing, State and County Housing Unit Estimates, County Business Patterns, Nonemployer Statistics, Economic Census, Survey of Business Owners, Building Permits. Retrieved July 3, 2014 from http://quickfacts.census.gov/qfd/states/26/26065.html U.S. Census Bureau. (2000). Census 2000, American Fact Finder. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src =bkmk Van Houtven, C. H., Voils, C. I., Oddone, E. Z., Weinfurt, K. P., Friedman, J. Y., Schulman, K. A., & Bosworth, H. B. (2005). Perceived discrimination and reported delay of pharmacy prescriptions and medical tests. Journal of General Internal Medicine, 20(7), 578-583. Wallerstein, I. (1984). The politics of the world economy: The states, the movements and the civilizations. Cambridge, MA: Cambridge University Press. Whitaker, J. (2009). Mexican deaths in the Arizona desert: The culpability of migrants, humanitarian workers, governments, and businesses. Journal of Business Ethics, 88(2), 365-376. Weiss, R. S. (1995). Learning from strangers: The art and method of qualitative interview studies. New York, NY: Simon and Schuster. Wolcott, H.F. (2001). Writing up qualitative research. Thousand Oaks, CA: Sage Publications. Zolberg, A. R. (1989). The next waves: Migration theory for a changing world. International Migration Review, 23 (3), 403-430. Zuniga, V., & Hernandez-Leon, R. (Eds.). (2005). New destinations: Mexican immigration in the United States. New York, NY: Russell Sage Foundation. 194