Criminalized Borders and US Health-Care Profits

I.

In mid-March 2020, just before New York City locked down, my partner and I traveled from there to Puerto Rico. We went to help support the care network that my mother built around my brother, who is neurodivergent, and my father, who lives with advanced Parkinson’s. As we left the city, it was facing a humanitarian collapse facilitated by the years of privatization its public health infrastructure had endured—a collapse depressingly similar to the one we had experienced in Puerto Rico after Hurricane Maria.

In the 1990s, the privatization of health care in Puerto Rico had devastating effects. Then, in 2015, the austerity policies of the colonial-debt crisis hit the public health-care system even harder. This further degradation meant that, after Hurricane Maria, in 2017, the Puerto Rican government was unable to communicate with or supervise private hospitals, account for patients with critical needs, or record the number of deaths from complications. These were not unlike the challenges facing New York as we left the city in March 2020.

Traveling back home in the middle of the pandemic drove me to reflect on those who can, or must, travel for health reasons. Specifically, I thought of those who travel from or to places that are not quite part of—but whose health-care infrastructure is stitched to—the US. I found myself returning constantly to the pages of a novel that addresses US-Mexico border crossings from a medical perspective. Piscinas verticales (Vertical pools), written by Mexican writer and translator Gabriela Torres Olivares, shows the multiple ways in which US imperialism has structured an unequal health-care system. It is these imperialist inequities that have been further exacerbated by the pandemic landscape.

 

II.

Torres Olivares’s Piscinas verticales recreates the last days of an American writer in an unnamed coastal border city in Mexico. Although the novel does not reveal the writer’s name, it offers enough clues to suggest it’s about the New York author Kathy Acker. In November 1997, the feminist cult figure crossed the border to Tijuana to seek alternative medical treatment for metastasized breast cancer. A doctor in San Francisco had just told her she was terminally ill. She would die in the Mexican city one month later.

Before reading the novel, I was aware of such health transits to Baja California; the Nuyorican poet Pedro Pietri undertook a similar journey to Tijuana, in 2004. Pietri, too, died of cancer—in his case, while en route back to the US. I was interested to learn that both Acker and Pietri, who were contemporaries, denounced the inequalities of the New York health-care system in the 1970s and ’80s.

Torres Olivares’s Piscinas verticales allows us to rethink the health inequities of today’s global pandemic. Specifically, the novel illuminates the seldom-explored role of the Mexican border zone as a supplier of medical services and equipment to the US. The novel compels its readers to reflect—in hemispheric terms—on how these health-care systems are structured binationally: stratified along lines of race, class, gender, disability, citizenship, and migration.

Global care chains are a major concern in the novel. But, instead of describing the transfer of immigrant labor from the global South to the North, Torres Olivares’s Piscinas verticales focuses on another, less visible transit: the North-to-South movement of US residents who enter Mexico to access lower-cost medical treatment.

The flow of cross-border patients—especially Latinxs who suffer discrimination in the US health-care system—has continued to grow, even since the implementation of the Affordable Care Act, in 2010. In 2015 alone, Baja California received approximately 1 million uninsured or underinsured travelers in search of affordable health services. The failure to reform health care and the cost of services only further this trend.¹

This trend points to significant deficiencies of the US system. Such transit also points to the complex political geographies of care that link the US to its supposed peripheries.

 

III.

The main character of Piscinas verticales is preparing a documentary about medical tourism in Tijuana. In each chapter, the third-person narrator explores a different gear of the health-care machinery. Together, these chapters portray the interstitial spaces that maintain and reproduce the larger health infrastructure: hospitals, medical-supply stores, and nursing homes. And it is these spaces, of course, that have become hypervisible during the COVID-19 crisis.

In one chapter, the narrator imagines what Kathy Acker might have thought about the urban landscape this health industry has configured:

Perhaps she was surprised by the effectiveness of one system when another does not work. The options that are engendered as a result of negligence, as well as the species that are only possible after mishaps, like the flowers that are born from forest fires and that cannot come to life in any other way. … There was no fire here but, like flowers, pharmacies appeared, and labs, doctor’s offices, nursing homes, structures were simultaneously built, technologies were imported, schools began to give birth to dentists and surgeons, bilingual specialists ready to go.²

In this passage, I am especially captivated by the comparison between Tijuana’s medical infrastructure and species that grow after climate disasters, the “flowers that are born from forest fires.”

The forms of life spawned in “precarious environments” is the subject of another book, Anna Lowenhaupt Tsing’s The Mushroom at the End of the World (2015). Tsing studies life-forms that are “willin[g] to emerge” in “human-disturbed forests,” such as matsutake mushrooms.³ In an echo of Tsing, Torres Olivares uses the word “habitat” to describe the infrastructure of medical tourism in Tijuana. This infrastructure, according to Torres Olivares, is a supplementary and transnational habitat that has emerged, like Lowenhaupt Tsing’s mushrooms, from precarity: the increasing inaccessibility of US health care.

A similar environmental vocabulary appears in another article, Shannon Mattern’s 2018 “Maintenance and Care.” Here, Mattern describes the emergence of “repair ecologies”—“illegal water taps, grafted cables, pirate radio stations, backyard boreholes, shadow networks, and so forth”—made necessary by the breakdown of broader social infrastructures.⁴ Torres Olivares writes about an even more delicate and complex “repair ecology”: an infrastructure dedicated to absorbing and managing care. Not in vain, the pandemic has moved President Biden to include care in his definition of infrastructure, and therefore in his new infrastructure plan.

Torres Olivares, Tsing, and Mattern all employ environmental language. Yet, in Torres Olivares’s case, the habitat metaphor invites us to think of our health-care system as a binational “networked assemblage,” made up of a range of entities and objects, humans and nonhumans.⁵ Nothing encapsulates this networked assemblage—on which the US and Mexico jointly depend—better than Tijuana’s role in producing and assembling medical equipment. At the beginning of the pandemic, no Tijuanan equipment was more critical than the artificial ventilator.

Since the implementation of the Border Industrialization Program, in 1965, and the 1994 North American Free Trade Agreement (now the T-MEC), Tijuana has become an industrial powerhouse in the medical-equipment sector. The city is home to more than 50 medical-supply-manufacturing companies.

Yet, in early April 2020, a newspaper article reported that medical-device-manufacturing corporations in Baja California were not required to sell or distribute any of their products in Mexico.⁶ The implication was that it was far more profitable to sell such essential medical equipment abroad. A painful public debate broke out across the country. By mid-April, Tijuana’s health-care workers were lacking the very equipment the city produced. They faced a shortage in ventilators, when the city was the 18th-biggest producer of medical supplies in the world.

Rather than highlighting the interconnection between Tijuana and care work across the world—including the US—Donald Trump, in June 2020, insisted on representing Tijuana as a threat to American health. This, too, he argued, was a threat that needed to be contained by the wall: “Can you imagine opening borders right now? Tijuana is the most heavily infected place anywhere in the world, as far as the plague is concerned.”

His statements on this issue, like so much else he put forward, were false. At the time of his speech, both San Diego County and Washington, DC, had registered more cases than Tijuana.⁷ Seeing the border as an ecology—one that remedies the devastation of the US’s health sector—contradicts the images of Tijuana that circulate in the mainstream.

Trump’s statement illustrates a dynamic that border-studies scholars have carefully theorized: the militarization of the border does not cut off cross-border circulation, but it does ensure that private companies reap profits. It is the intensification of border controls that regulates these transnational care markets, devaluing care work and the labor that creates care equipment to ensure its private capture.

 

IV.

While the question of medical supplies involves the transit of goods, Piscinas verticales explores (among other things) the transit of people. Specifically, the novel explores the link between punitive migratory policies and the viability of Tijuana’s medical-tourism industry, whose profitability depends on the low-cost offering of medical services.

In one chapter of Piscinas verticales, the main character interviews migrant women who, after working as caregivers in the US for many years, end up being deported to Tijuana. There, they offer their services as caregivers outside of hospitals and private clinics. In Tijuana they’re known as “canaries,” because of their “singing,” the author tells us; because they helpfully warn “qualified” medical personnel when patients worsen.

However, the doctors also call them “sparrows,” to devalue their work: “Sometimes nurses, doctors, and stretcher-bearers look at them with apprehension and suspicion … being derogatory, they call them sparrows and not canaries, like common, stray sparrows, species introduced into the hospital ecosystem, most are migrants, deported.” These laborers are not properly considered health-care workers, nor are they remunerated accordingly. The novel thus reveals how deportations facilitate a stratified health-care system, which is sustained by the precarious, poorly paid work of the migrant.

The intensification of border controls regulates transnational care markets, devaluing care work and the labor that creates care equipment to ensure its private capture.

Indeed, the COVID-19 pandemic has thrown into sharp relief the hierarchies of the care industry, drawing clear lines between “essential” health-care workers and the rest: the unprotected, undignified, deportable care worker. The latter have been constantly fired without compensation, stigmatized as possible carriers of the virus, and judged for not being able to isolate themselves. As Natalia Mendoza observes, the pandemic has intensified a political economy based on the proliferation of border controls. These are now installed not only at the state level, but between cities, between neighborhoods, between bodies.⁸

 

In the context of the pandemic, so-called essential workers are forced to make dangerous cross-border transits through boroughs or neighborhoods. Such workers risk becoming infected, falling sick, and dying, all in order to take care of those of us who have the luxury to work from home.⁹

Torres Olivares’s novel constantly points not only to the ways in which border regimes produce vulnerable healthcare workers. It also emphasizes how a privatized and discriminatory health-care system operates as an interior border regime: by obstructing access for impoverished and racialized populations.

 

V.

Torres Olivares’s prose has led me to rethink my own family history and the history of Puerto Rico, especially its role as a biological and economic laboratory for the US health industry. During key years in the neoliberalization of the US health system, the Puerto Rican archipelago was treated as supplementary industrial infrastructure—analogous to the human and industrial infrastructure provided by Tijuana today. The universe of images and metaphors presented in the novel have thus hit close to home.

Last summer, the Colectiva Feminista en Construcción staged a protest at an Abbott Pharmaceutical plant in Caguas, Puerto Rico. This action denounced the lack of COVID-19-testing materials on the island, despite the fact that, in 2019 alone, medical supplies represented 74 percent of all Puerto Rican exports. Multinationals like Abbott and Roche, explained Shariana Ferrer-Núñez, the Colectiva’s spokesperson, manufacture molecular testing devices. Yet, despite having received tax exemptions for decades for doing so, they are unwilling to supply the island with essential materials to test its population.

At the time of this protest, I was in Puerto Rico, writing about Piscinas verticales. My attention was drawn to how the protest—much like the novel—helped in narrating the pandemic.

The protest evoked an entire history of colonial relations between Puerto Rico and the US as it pertains to health care. This is a colonial history whose weight has been carried mostly by feminized bodies. Experiments with IUDs and birth-control pills were carried out on Puerto Rican women in the mid-20th century, while mass sterilization programs affected one-third of Puerto Rico’s female population of childbearing age during that time, including my grandmother. These eugenic practices were intended to secure and retain female workers for Puerto Rico’s industrial sector during “Operation Bootstrap,” the federal economic plan to industrialize the island. By the 1970s, Puerto Rico began being replaced as a manufacturing hub by border cities like Tijuana.

In 1976, Section 936 of the US Internal Revenue Code was ratified. By providing federal tax exemptions to US corporations operating in Puerto Rico, the archipelago was transformed into one of the largest pharmaceutical-manufacturing hubs in the world, and, until 2017, provided more pharmaceutical products to the US than any other state or foreign country. Like Tijuana today, it became an important biotechnology manufacturer and supplier of medical devices to the US. My mother worked for one of these pharmaceutical companies for almost 30 years.

Section 936 was repealed in 2006. Today, Puerto Rican politicians and neoliberal “experts” see the current COVID-19 crisis as an opportunity to revive these biotechnological dreams. But the Colectiva’s intervention interprets the pandemic in a different way, one that interrupts the consensus built around these dominant development models.

Feminist writers in Puerto Rico have insisted on the need to narrate the debt and the ruin of colonial utopias. And they demand that this narration be driven not by the neoliberal abstraction of expert discourses, but by the perspectives of those who have suffered the consequences of being indebted.¹⁰

In a similar vein, the act of narrating the pandemic allows us to link global patterns to our personal histories and trajectories. Even though Torres Olivares’s novel preceded the pandemic, her prose makes visible, as the Colectiva does, the uneven geopolitics of care that have historically linked the US and its supposed borderlands and peripheries. Narrating the pandemic would be a step toward subverting the abstract neoliberal geopolitics of health care that have made the COVID-19 pandemic a greater tragedy than it had to be.

 

This article was commissioned by Geraldo Cadava.