Book Review: Landscapes of Care

Landscapes of Care: Immigration and Health in Rural America, by Thurka Sangaramoorthy (2023). Chapel Hill, NC: University of North Carolina Press.

In her new ethnography Landscapes of Care, Thurka Sangaramoorthy renders visible the changing health landscape of Maryland’s rural Eastern Shore by tracing how non-citizen immigrants and healthcare providers navigate it. Sangaramoorthy illustrates how precarity, exclusion, and informal networks of exchange have come to shape what she calls a “landscape of care.”

Sangaramoorthy’s narrative develops around “immigrants’ and rural providers’ shared condition of uncertainty and disposability,” what she describes as the “precarity” common to both immigration and rural life (xiv). Crucially, the book attends to the ways in which this instability is inhabited and made viable through a network of relations—a “landscape” that connects ongoing histories of rural disinvestment, racialization, labor immigration, moral and material exchange, and forms of insurance—rather than a temporally and spatially fixed model of healthcare.

In Chapter 1, entitled “Journeys through the Heartland,” Sangaramoorthy situates the increase in immigration to rural areas of the United States, especially in Maryland. The author traces global economic restructuring from the perspective of the rural Eastern Shore, showing how the decline of manufacturing and small-scale farming have paralleled the rise of low-wage employment in the agricultural, poultry, and seafood sectors. Unable to attract local workers with low wages and emboldened by immigration policy, these employers rely primarily on the exploitation of racialized migrant labor. This history reveals how the joint withdrawal of the state and capital from rural communities has produced an increased reliance on racialized migrant labor in low-wage, labor-intensive industries. As Sangaramoorthy illustrates, rural abandonment is also materialized on the Eastern Shore due to a lack of formal healthcare resources. Migrant workers, who already face significant social and infrastructural barriers to receiving adequate healthcare, are disproportionately affected by local resource scarcity. Here, Sangaramoorthy highlights how the delivery and experience of healthcare in rural Maryland are inextricably linked to racial capitalism.

This analysis is further explored in the following chapter, which introduces to readers several migrant workers and their experiences in these industries. Through a series of ethnographic accounts, Sangaramoorthy illustrates how racialized work conditions shape immigrants’ experiences and adversely affect their health and well-being, increasing the risk of injury and further complicating the accessibility of care. Critically, this chapter shows that routinized forms of racial discrimination and injury are fundamental to the process of capital accumulation on the Eastern Shore.

Landscapes of Care most incisively illustrates the barriers to healthcare and the strategies that migrants and rural providers use to navigate them. Healthcare systems on the Eastern Shore, like those elsewhere in rural America, are constrained by provider shortages, large numbers of under-insured and ill patients, and a lack of public investment. In Chapter 3, these difficulties, alongside anti-immigration policies and discrimination, are shown to impact how immigrants come to experience care. Sangaramoorthy’s provider-interlocutors explain their realities as caregivers as being overburdened and under-resourced, while many migrant-interlocutors detail their “sheer exhaustion and uncertainty” of navigating complex healthcare bureaucracies that demand evidence of documentation in addition to onerous fees (85). By detailing the systemic barriers faced by immigrants and the perspectives of exhausted care providers, Sangaramoorthy reveals the “exclusionary, extractive, and profit-driven nature of health care” (76).

Given this context, how do immigrants and rural providers generate care? Chapter 4 develops the concept of “Band-Aid care,” referring to the temporary, improvised, and informal fixes that make life possible on the Eastern Shore, particularly for immigrants whose barriers to formal healthcare are nearly insurmountable. “Band-Aid care” is depicted in vivid ethnographic detail as being administered through bartering, rationing, hoarding, willful non-compliance, and the goodwill of personal relationships. For example, Sara is introduced, a rural healthcare provider who meticulously saves unused medications to distribute at no cost to uninsured clients. There is also William, an undocumented farmworker who spends the winter working in Florida and returns to Maryland for care, where he experiences less exclusion ary treatment and can obtain enough medication to last him through the season (103).

Through these detailed accounts, Landscapes of Care achieves two important objectives: it highlights the unequal ways in which capital structures healthcare on Maryland’s Eastern Shore and examines how migrant workers are negatively affected by economic and healthcare disparities. At the same time, the author refuses to simplify the overlapping issues of immigration and rurality to their associated hardships, or to position immigrants and rural places as passive recipients of devaluation and abandonment. Sangaramoorthy foregrounds interdependent patient-provider relations as providing “opportunities (however fraught) for living—to be something, rather than nothing” (113).

Drawing on her background in public health and a rich set of ethnographic data, Sangaramoorthy analyzes a critical—though understudied—intersection of labor immigration, healthcare, and rurality in the United States in a way that is both incisive and compelling. In this regard, Landscapes of Care is a significant addition to the anthropological literature on immigration and health in the United States, by shifting the focus from legality and criminality to economies, place, and social relations. Anthropologists who study rural America will find the book’s insights into disinvestment, the political economy of rural immigration, and racialization generative. Sangaramoorthy’s analytical attention to the disruptions and possibilities that emerge in contexts of spatialized and racialized vulnerability will be productive for interdisciplinary scholars seeking to understand and represent precarity without making it into a totalizing condition. As such, Landscapes of Care serves as a warning for what happens when people and places become disposable, without losing sight of how such devaluation can be contested and resisted. For this reason, Sangaramoorthy’s study of emerging networks of care in Maryland’s Eastern Shore will be an important work in public health and medical anthropology for years to come.