Abstract
The Rio Grande Valley of Texas has an exceptionally high number of COVID-19 cases and case fatality rate. The region makes up only 3% of the Texas population but, as of April 2021, accounted for 9% of the state's COVID-19 deaths. Additionally, during the summer of 2020, the Rio Grande Valley had one of the highest per capita infection rates in the United States. This paper explores the social-ecological elements that impact health-seeking behaviors in this community using interviews conducted with healthcare personnel and nonprofit leaders in the Rio Grande Valley between 2019 and 2020. Using this data, we found that anti-immigrant rhetoric has increased levels of fear among immigrants and mixed-status families, which has made them less willing to access healthcare. Additionally, we found that changes in the public charge rule has led to a decreasing number of children accessing government-provided health insurance. Our findings suggest that these outcomes likely contributed to the severity of the COVID-19 outbreak in the Rio Grande Valley.
Introduction
The first case of COVID-19 was confirmed in Texas on March 4, 2020, 1 and more than a year later cases have remained high across the state. A disproportionately high number of cases and deaths have occurred in South Texas where, by April 8, 2021, 4.4% of total statewide cases were in the 4 counties—Cameron, Hidalgo, Starr, and Willacy—that make up the Rio Grande Valley along the Texas–Mexico border. 2 The Rio Grande Valley is located at the southern tip of Texas and runs about 100 miles along the United States–Mexico border from the Gulf of Mexico. The Spanish first occupied the region in 1750, but the first American city was not established until 1846 when Fort Brown (later Brownsville) was founded during the Mexican War. 3 Due to irrigation and the railroad, the Rio Grande Valley quickly became the prosperous agricultural center, which it remains today.
Despite the rapid growth experienced in the 1970s, the region remains one of the poorest in the United States 4 and the poorest urban area in Texas. The poverty rates in the region range from 28% in Cameron County to 35% in Willacy County. 5 The rates of child poverty are even higher, ranging from 45% to 49%. 6 The average median annual household income between the 4 counties is $33,692. The high rates of poverty in the Rio Grande Valley combine with a high percentage of the population without health insurance. As a state, Texas's uninsured rate is double the national average at 18.4%. 7 In the 4 counties, the percentage of the population without health insurance is even higher at 22.6% (Willacy), 29.9% (Starr), 30.2% (Cameron), and 32.1% (Hidalgo). 5 Among children in the Rio Grande Valley, the uninsured rate declined between 2008 and 2015 from 10% to 13%, depending on the county, and has risen even higher over the last few years. 8 The combination of high poverty rates, low health insurance coverage, and a high percentage of Latinx immigrants during a time of increased anti-immigrant sentiment in the United States made the Rio Grande Valley uniquely positioned to be hit hard by the COVID-19 pandemic.
As of April 6, 2021, Hidalgo and Cameron counties, the 2 biggest counties in the Rio Grande Valley, have had 9,974 and 9,217 COVID-19 cases per 100,000 population, respectively. This is compared to 8,184 and 6,504 COVID-19 cases per 100,000 population, in Harris County (Houston) and Travis County (Austin), respectively. 2 In addition to the Rio Grande Valley's high infection rate, it also has a high case fatality rate. Although the region makes up only 3% of Texas's total population, as of April 8, 2021, it accounts for 9% of the state's COVID-19 deaths. 4 As of March 2021, Hidalgo County had 282 deaths per 100,000 population and Cameron County had 339 deaths per 100,000 population. By comparison, Harris County had 122 deaths per 100,000, and Travis County had 74 deaths per 100,000 population. 2 The disproportionate infection and death rates in the Rio Grande Valley are the result of the region's demographics and existing health inequities, compounded by anti-immigrant rhetoric, which escalated during the Trump Administration.
Pre-COVID-19 Health Inequities
Before the outset of the COVID-19 pandemic, the Rio Grande Valley had longstanding health inequities that made them especially vulnerable to SARS-CoV-2, the pathogen that causes COVID-19. More than 90% of the Rio Grande Valley population are Latinx. 9 While only 5% of children in Rio Grande Valley are not US citizens, more than 50% of them have 1 or more parents who are immigrants. 10 Additionally, of the children with 1 or more parents who are immigrants, half of those children have at least 1 parent who is not a US citizen. 10
As of 2018, the overall rate of diabetes in the Rio Grande Valley was 14.4%, but the rate of diabetes among the Latinx community was much higher at 24.9%. 11 An even greater disparity exists between the Latinx diabetes rate in the region and the State of Texas diabetes rate, which is 11.5%. The large health disparities continue with the obesity rate. The statewide rate of obesity is 33%, while in Cameron and Hidalgo counties it is 41.6%. Among the Latinx population in Cameron and Hidalgo counties, however, the rate is 48.3%. 11
The high rates of obesity and diabetes in the Rio Grande Valley are products of and compounded by other health and socioeconomic inequities between the border region and the rest of the state and between White and Latinx border residents. The rate of undiagnosed diabetes is especially high among individuals of low socioeconomic status, and the rate of complications and death from undiagnosed or untreated diabetes is higher in Mexican Americans than among the White population. 12
The reason for such high rates of undiagnosed or untreated diabetes has to do with the substantially higher rates of uninsured individuals in the Rio Grande Valley compared to the rest of the state. 7 Among uninsured Texans, 61% of those without insurance identify as Hispanic, compared to 12% of those who identify as non-Hispanic. 7 Additionally, 36% of Texans who are uninsured have at least 1 noncitizen in their family. In Hidalgo County, 97% of the uninsured identify as Hispanic, whereas only 2% of the uninsured identify as White. 13 Additionally, 64% of uninsured individuals in the county have at least 1 family member who is a noncitizen. When examining the South Texas region as a whole, much of which includes the Rio Grande Valley, 57% of those who are uninsured have at least 1 family member who is a noncitizen. 14
These preexisting health inequities in the Rio Grande Valley, particularly as reflected in rates of uninsured individuals, increased during the Trump Administration, as did anti-immigrant rhetoric. In this paper we examine how anti-immigrant rhetoric impacts health-seeking behavior among immigrants in the Rio Grande Valley of Texas and how this exacerbated existing health inequities during the COVID-19 pandemic.
Methods
To understand the impact of anti-immigrant rhetoric on health access in the Rio Grande Valley, and subsequently the high number of COVID-19 cases, we conducted in-depth interviews with 13 local healthcare professionals, nonprofit leaders, and members of the Latinx community. These interviews took place over 14 months between September 2019 and November 2020. Some of the participants we spoke with on multiple occasions. Of the 13 people interviewed, 2 were medical doctors, 4 worked for nonprofit organizations, 2 were members of the clergy with medical expertise, and 5 were members of the immigrant community (Table 1). Participants were selected through snowball sampling. Interviewees who were members of the clergy were particularly important in helping us schedule interviews with members of the immigrant community.
Interviewee Demographics (N = 13)
Ten interviews were completed in-person and 3 interviews were completed over the phone; the latter were conducted with participants from the nonprofit category. All interviews were conducted in a semistructured manner, with a set of questions for individuals who work with the immigrant community (Table 2) and a set of questions for individuals who are members of the immigrant community (Table 3). Because the interviews were semistructured, additional questions were asked to some interviewees to allow us to delve deeper into topics they brought up during the interview. Interviews were conducted in the participants' preferred language—whether English or Spanish. Due to the sensitive nature of the interviews and the immigration status of some involved, interview responses were recorded by handwritten notes only.
Interview Questions for Individuals Working with Immigrant Community
Interview Questions for Members of the Immigrant Community
After the interviews were completed, we conducted a thematic analysis of the interview content, 15 looking for recurring patterns that spoke specifically to the health-seeking behavior of members of the Rio Grande Valley immigrant community. Although the interviews we conducted were extensive, 2 patterns were central to all of them. The first pattern was that increased levels of fear due to intensified anti-immigrant rhetoric during the Trump Administration deterred both lawfully present and undocumented immigrants in the Rio Grande Valley from seeking needed healthcare. The second was that changes to the public charge rule made by the Trump Administration had a substantial and measurable impact on the willingness and ability of lawfully present and undocumented immigrants to access healthcare. 16
Results
Thematic analysis of the 13 interviews demonstrated 2 primary patterns: increased levels of fear due to intensified anti-immigrant rhetoric during the Trump Administration deterred both lawfully present and undocumented immigrants from seeking healthcare and changes to the public charge rule made by the Trump Administration had a substantial and measurable impact on lawfully present and undocumented immigrants' willingness to access healthcare. In this section, we detail these findings.
Increasing Levels of Fear
Healthcare providers, nonprofit leaders and staff, and members of the immigrant community who we interviewed frequently discussed increasing levels of fear among immigrants due to anti-immigrant rhetoric during the Trump Administration. Below we have provided examples of quotes obtained from interviews, which highlight this fear.
Sometimes the Border Patrol are [sic] at the clinics. Sometimes they park in the parking lots.
Anti-immigration rhetoric is hurting everyone, but especially children.
Border Patrol sits outside colonias so people are afraid to leave. They sometimes miss their appointments because of this.
Now with the attacks on immigrants, people don't want to get Medicaid anymore, even if their children really need it.
They want to see Trump out of office before they can trust anything again.
Changes to Public Charge Rule
Many of the individuals we interviewed spoke extensively about the impacts of the changes to the public charge rule made by the Trump Administration. Though the recurrence of this pattern was not as frequent as fear caused by anti-immigrant rhetoric, many interviewees discussed how confusion over the changes led to a decrease in enrollment for US citizen children of noncitizen parents. We have provided examples of quotes obtained from interviews, which highlight the impact of the public charge changes.
People will remove their children from CHIP [Children's Health Insurance Program] out of fear, even if public charge doesn't apply to them.
There has been a significant decline in CHIP, Children's Medicaid, and SNAP [Supplemental Nutrition Assistance Program] since 2017 [when the public charge changes were announced].
Even the term “public charge” scares people. They don't want to be a burden on these programs.
Mixed-status families stay away from the programs because, even if they are legal, they don't want to expose other family members.
Discussion
Increasing Levels of Fear
Providing healthcare services in the Rio Grande Valley has always been a challenge because of the unique dynamics of the border communities, which include poverty, immigration status, and language barriers. Even so, all of the individuals that we interviewed who are either healthcare professionals or work on issues of health access for immigrants, stated that almost every immigration-related policy that was implemented during the Trump Administration made it more difficult to provide services to both immigrants and citizens in the community. Additionally, the increased presence of Border Patrol in places that are termed “sensitive locations,”—such as, hospitals, schools, and places of worship, which are supposed to be protected from Immigration and Customs Enforcement (ICE) and the Border Patrol—has served to increase community fear. Border Patrol presence at hospitals and clinics, combined with incidences in which patients have been removed from hospital settings and deported, has led to what many interviewees described as a noticeable decline in willingness to access healthcare.
An interviewee who provides health services via a mobile clinic discussed how it is becoming more difficult to provide health services in this manner due to increasing levels of fear among the populations the mobile units are designed to serve. This can be an especially large challenge in colonias—low-income rural communities that often have higher levels of immigrants residing in them—because the Border Patrol began following the mobile units during the Trump Administration. Colonias also often lack basic infrastructures such as running water and solid waste disposal, making it more difficult for multigenerational households to protect themselves from viruses like SARS-CoV-2. 17 According to 2011 Census data, 18 between 60% and 65% of individuals in colonias in the Rio Grande Valley either live in poverty or near poverty. In further expanding on the challenges experienced, one healthcare provider said that Border Patrol presence near mobile units trying to provide health services deterred people from coming out of their homes and taking advantage of the care they would otherwise not be able to access or afford.
Many individuals we interviewed mentioned incidences in which clinic or hospital staff had called ICE about undocumented individuals who had sought care at a hospital or clinic, further amplifying the community's fear about accessing healthcare. These actions, which are against ICE official policy, 19 often deter even US citizens or lawfully present immigrants from seeking healthcare because they feel such actions could put an undocumented family member at risk.
Overall, all of the 13 individuals that we interviewed felt strongly that the Trump Administration's immigration policies and the growing national anti-immigrant rhetoric had created not only a toxic environment but also an environment in which undocumented, lawfully present, and even US citizen children are less willing and able to access healthcare. Delaying healthcare, or an unwillingness to access it altogether, put members of the Rio Grande Valley immigrant community at increased risk of severe illness and/or death from both acute and chronic diseases and likely contributed to the extremely high rate of undiagnosed and untreated diabetes.
However, the increasing levels of fear among lawfully present and undocumented immigrants is only part of their apprehension for seeking and accessing healthcare in the Rio Grande Valley. Policy changes aimed at cutting off services to immigrant communities also had a notable impact and will have long-lasting effects on the health status of border communities despite corrections made by the Biden Administration in February 2021. 16
Changes to Public Charge Rule
In 2017, not long after President Trump took office, a number of executive orders were leaked that had the effect of increasing fear and inciting rumors in immigrant communities across the United States. The changes in policy and escalated debate around immigration affected approximately 23 million non-US citizens, which includes lawfully present and undocumented immigrants, and more than 12 million US-born citizen children, who live with a noncitizen parent. 20 The most impactful of these orders were the changes that the Trump Administration proposed to the public charge rule. 16 The public charge rule has been on the books for decades and is a test given to individuals living outside the United States who are seeking residence in the United States. If it is determined that an individual will become dependent on the government for the majority of their life, the public charge rule prohibits them from immigrating. The original changes to this rule proposed by the Trump Administration, however, stated that the use of any public service would count against someone seeking a green card, even if the service was used by their US citizen children.
In early 2020, the Trump Administration incorporated SNAP, Medicaid, housing assistance, and federal, state, local and tribal cash assistance into the public charge measure. 21 Immigration officials also took into account a person's age, health, family status, education, and role as a caregiver when determining if they will become dependent on the government. Some factors were more heavily weighted than others; for instance, a person's income could either help or hurt a person's chances at being granted US residency. 22 Under these changes, immigration officials were given plenty of leeway to make judgments, and immigrants were given little hope for a chance at safety and opportunities to improve their quality of life. All of the individuals we interviewed stated that the scope of the revised rule sparked enough fear and confusion that the announcement alone affected health access for those in the Rio Grande Valley and across the State of Texas.
The initial announcement of changes led to a large decline in CHIP, children's Medicaid, and SNAP enrollment in the State of Texas. Therefore, individuals, most of whom are US citizens, who would have otherwise had health insurance, enabling them to financially access healthcare, had been voluntarily forgoing such coverage due to the Trump Administration's proposed changes to the public charge rule. Data on children's health coverage shows that the number of Texas children enrolled in Medicaid and CHIP decreased by about 6% between December 2017 and November 2019. 23 This 2-year decline in health insurance coverage, particularly among children in Texas, arrived ahead of the COVID-19 pandemic. Additionally, the changes to public charge took effect in February 2020, just as the pandemic was taking root in the United States, leaving many in the Rio Grande Valley even more marginalized and unprepared when COVID-19 hit.
Conclusion
As of April 8, 2021, there were 105,553 cases in the Rio Grande Valley. 2 The 2 largest counties, Hidalgo and Cameron, rank 8th and 14th, respectively, in the highest number of overall COVID-19 cases in Texas. These numbers and rankings, however, obscure the high number of deaths and the even higher case fatality rate of counties in the Rio Grande Valley. Hidalgo County had reported 2,485 COVID-19 deaths, making it the county with the 6th highest number of deaths in the state. The counties with higher total death counts were those that include Houston, Dallas, San Antonio, Fort Worth, and El Paso, all cities with much larger populations. The outsized death rate did not just impact Hidalgo County. The case fatality rates for the Rio Grande Valley were 3.7%, 4.4%, 3.8%, and 3.7% in Cameron, Hidalgo, Starr, and Willacy counties, respectively. By comparison, the case fatality rates for Bexar (San Antonio), Dallas (Dallas), Harris (Houston), and Travis (Austin) counties were 1.9%, 1.5%, 1.5%, and 1.2%, respectively. Even El Paso County, which includes the city of El Paso and received national attention during the fall of 2020 for its number of COVID-19 deaths, had a case fatality rate of 2.0%. In sum, the case fatality rates in the Rio Grande Valley were double or triple the case fatality rates in Texas's largest cities.
The anti-immigrant rhetoric in the United States and the Trump Administration's focus on eliminating protections and rights for both lawfully present and undocumented immigrants helped to create an environment of fear and unwillingness or inability to access healthcare leading up to the COVID-19 pandemic. Such actions served to compound existing health inequities in the immigrant communities within the Rio Grande Valley. The lack of access to healthcare and the high poverty rates of the Rio Grande Valley contribute to the high percentage of the population with underlying conditions. These underlying conditions were allowed to develop, worsen, and mostly go untreated due to a lack of financial access to healthcare or fear of accessing care that has been heightened as a result of the Trump Administration's immigration policies.
The compounding nature of these health inequities with the anti-immigrant environment left people exposed and without access to healthcare, contributing to the Rio Grande Valley having one of the worst COVID-19 outbreaks in the United States. This level of fear about seeking health services and immigrant communities' inability to seek or use health services has put not only these communities but also the rest of the nation at risk from diseases like COVID-19. The existing health inequities exacerbated by COVID-19 provide an opportunity to develop border health policies that can widen, rather than constrict, access to care. At the federal level, changing the way that we talk about immigrants and promoting policies that support human rights will help to lessen the current levels of fear. Additionally, enforcing the “sensitive locations” component of ICE policy 19 will allow both lawfully present immigrants from mixed-status families and undocumented immigrants to access healthcare without fear of deportation.
At the state and local level, medical professionals, public health officials, and medical nonprofits should continue to fight rumors related to the public charge rule. Engaging community health workers and building a trusting relationship within immigrant communities in the Rio Grande Valley may help counter some of the rumors around the rule and may encourage families to re-enroll their eligible children in programs like SNAP and CHIP. Establishing an environment in which all individuals can access healthcare, regardless of their own or their family members' immigration status, is necessary for infectious disease prevention and containment, chronic disease prevention and management, and the overall health security of the United States.