In eastern Tennessee, doctors have seen firsthand how a hard-line immigration policy can affect the health and well-being of a community.
In 2018, federal agents raided a meatpacking plant in Morristown, a manufacturing hub in the Tennessee Valley, and detained nearly 100 workers they suspected of being in the country illegally. In the weeks that followed, scores of immigrant families who had found work in the meat-processing plants dotting broader Hamblen County scrambled to find sanctuary in churches — and scrupulously avoided seeking medical care.
The reason? Immigration agents were staking out clinics.
"We did not want people to come in for care because there were ICE officers in our parking lot," said Parinda Khatri, chief clinical officer at Cherokee Health Systems, a nonprofit provider in Hamblen County.
As Tennessee, like other states, embarks on the daunting task of inoculating millions of residents against covid-19, many health officials find their mission complicated by a pervasive mistrust of government and law enforcement among unauthorized immigrants, a population estimated at 11 million across the U.S.
The challenges are particularly acute in the South, where large populations of immigrants living there illegally help maintain the region's thriving agricultural and food-processing industries even as many state and local Republican leaders, emboldened by the Trump administration's four years of anti-immigrant vitriol, denounce unauthorized residents as criminals and call for more limited paths to citizenship.
The confluence of those aggressive attitudes and a highly contagious virus has prompted concerns in some states that lackluster vaccination of people in the country without legal permission will short-circuit efforts to achieve herd immunity for the broader community.
"We will never get on top of this pandemic if the undocumented are left out," said Dr. Sharon Davis, chief medical officer at Los Barrios Unidos Community Clinic in Dallas, which serves 28,000 patients, the majority of them in the country without authorization.
She acknowledged the challenge that poses in a state such as Texas, where the state Republican Party platform calls for the immediate expulsion of all "illegal aliens." Echoing clinic directors in many Southern states, Davis said rolling out vaccination plans in immigrant communities is a "don't ask, don't tell" policy.
"We live in Texas, so you don't bring it up. You don't mention it," she said. "We talk about the uninsured, and we talk about the Latinx population with the highest morbidity and mortality — that's who we're trying to serve."
In the Dallas-Fort Worth area, home to one of the nation's largest populations of unauthorized immigrants, the covid death rate for middle-aged Latino men is eight times higher than for their non-Latino white counterparts.
Epidemiologists say the disparity is not surprising, given vast numbers of Central and South American workers in the country illegally are doing jobs deemed essential in the pandemic, including farm labor, meat-processing and food service, and most have no health insurance.
Compounding the risks, many of these workers labor in conditions ripe for viral spread, standing shoulder to shoulder along conveyor belts in vegetable-packing houses, washing dishes in restaurant kitchens, stocking grocery shelves and cleaning hotel rooms. At day's end, many return to bunkhouses or cramped homes housing multiple generations of family.
"It's going through the whole house, and if the whole house doesn't work, they don't eat," Davis said. "We've had patients begging us not to test them, because then they can't go to work."
Davis was among the medical directors who said the mass vaccination sites many states are using in the rollout — giant tents staffed by uniformed National Guard troops and iPad-toting medical personnel — have spooked immigrant families.
"They are asking, 'What documentation do we have to show at the mass vaccination sites?'" said Davis. "Fear of deportation is just huge, and very real."
And not unfounded, advocates noted, coming off four years in which former President Donald Trump sharply curtailed both legal and illegal immigration through mass detention and deportation, travel bans and severely restricting asylum. President Joe Biden has pledged to undo many of Trump's policies, but immigrant advocates say support for more drastic measures runs strong among some immigration agents and local law enforcement officers, who could make life difficult for immigrants they suspect are in the country illegally.
Beyond fear of harassment or arrest, Davis said, public health officials are dealing with misinformation, including widespread rumors about government surveillance efforts secreted in the vaccine. "They are hearing horrible stories on social media," she said. "They believed there was a microchip in the vaccine and they would be tracked."
Even some immigrants living in the U.S. legally have reservations about receiving a government-provided vaccine. The Trump administration pushed to derail citizenship for any immigrant who used taxpayer-funded public services, including health care. In December, the Department of Justice withdrew the rule, but confusion abounds, and clinic directors say patients will prioritize their green cards above almost all else.
Sluggish vaccination rates among immigrant populations are already apparent. In Mississippi, for example, the Department of Health reported last week that fewer than 2,800 Latinos have been vaccinated — about 1% of all vaccinations administered so far.
Tennessee offers a prime example of the tensions underlying the vaccine rollout.
The Republican governor, Bill Lee, made headlines in May when he allowed the state Department of Health to share the names and addresses of those who tested positive for the virus with police. The city of Nashville's health department separately provided local police with the addresses of people who tested positive or were quarantining.
Both efforts came under criticism and eventually ended, but Lee defended the effort, saying the information was "appropriate to protect the lives of law enforcement" and permitted by federal health privacy laws. The city later sought to reassure its "diverse immigrant communities" that the information would not be shared with federal immigration authorities.
Alabama, like Tennessee, has a history of tough rules regarding immigration, including a sweeping 2011 law that bars unauthorized immigrants from receiving nearly all public benefits, including most nonemergency medical care.
Velvet Luna, a 26-year-old registered nurse, has built her life in Ozark, Alabama, a small city in the Wiregrass, a region known for its poultry-processing facilities and large populations of Hispanic and Vietnamese immigrants. Luna enrolled in Deferred Action for Childhood Arrivals, or DACA, an Obama-era program that granted temporary status to unauthorized immigrants brought across the border as children. According to the National Immigration Law Center, nearly 500,000 DACA-eligible immigrants are essential workers.
Luna, who speaks with a soft Southern accent, once freely shared her immigration status, she said, but in recent years men who flirted with her "would find out my status and they would immediately change their attitude toward me. They would say ugly, ugly, hurtful things. 'You are the reason our country is declining. You need to get out of here.'"
As a nurse at an area hospital who volunteered in the covid unit, she has received both doses of vaccine, but she understands the risks undocumented families weigh; neither of her parents, who live close by, are authorized to be in the U.S. "It's OK to be scared, and it's a courageous move to go get the vaccine and protect your family," she said.
Even hard-line immigration opponents acknowledge the pandemic has tied together the fates of everyone living in the U.S., regardless of how they arrived.
"The main thing is to get shots into as many people's arms as possible," said Mark Krikorian, executive director of the Center for Immigration Studies, a conservative think tank that strenuously advocates for restricting immigration. "Your immigration may catch up with you someday, but that's not today."
The Biden administration has said U.S. Immigration and Customs Enforcement will not conduct enforcement operations at or near vaccine distribution sites. "ICE does not and will not carry out enforcement operations at or near health care facilities, such as hospitals, doctors' offices, accredited health clinics, and emergent or urgent care facilities, except in the most extraordinary of circumstances," according to a Feb. 1 statement issued by the Department of Homeland Security.
State health commissioners also have tried to calm rattled nerves. "We are not denying vaccine to anyone who shows up at our sites and is in a phase," said Dr. Lisa Piercey, commissioner of the Tennessee Department of Health. "This is a federal resource, and if you're in this country, then you get a vaccine."
Advocates, however, said hurdles remain in convincing wary emigres that the personnel information collected as part of the vaccination process will not be used against them. The Centers for Disease Control and Prevention expects providers administering covid vaccines to upload patient information to state registries, including TennISS in Tennessee or ImmTrac2 in Texas. The tracking systems allow providers to ensure patients return for their second dose, and to identify any adverse reactions.
The use of such information for health initiatives, not immigration crackdowns, is a nuance that providers struggle to explain.
"Patients, particularly those of immigrant origin, are highly sensitive to sharing family details," Brian Haile, executive director of Neighborhood Health, a community clinic in Nashville, wrote to Tennessee health officials in December. "If we ask them to provide this information to providers they do not know, they will be even more reticent to have their families get vaccinated."
In Hamblen County, Khatri said she's trying to persuade those laboring on tomato and tobacco farms and in meat-processing plants — hot zones of coronavirus outbreaks — to trust her clinic not only to administer the vaccine but also to handle sensitive data.
"They want to go to a trusted group," said Khatri, whose clinics have received approval to distribute the vaccine but have not yet received any doses.
Helena Lobo, who coordinates Hispanic outreach at Cherokee Health, echoed that, saying, for some immigrants, the choice may come down to choosing their health or choosing to remain hidden.
"If they have to risk their immigration status to have the covid vaccine, they will not have it. I don't blame them," said Lobo. "They go by risk: 'What is my biggest risk? Being deported or to have covid?'"