EL CENTRO, Calif. — When Manuel Ochoa started feeling sick — his body sore, his breathing restricted — he drove from his mother’s home in Mexicali, Mexico, to the U.S. border.
The 65-year-old retiree parked his car at the border crossing and tried to drag himself to the country where he has permanent residency, and where his health insurance is valid. Just before he approached the port of entry, he collapsed in the sun.
That’s when U.S. immigration officials made a call that has become increasingly common during the coronavirus outbreak: for an ambulance to transport a U.S. citizen or resident from the Mexican border to the nearest American hospital.
As Mexico’s health-care system has strained under the coronavirus, small community hospitals in Southern California, some of the poorest in the state, have been flooded with Americans who have fallen ill and crossed the border. They are retirees and dual citizens, Americans working in Mexico or visiting family there.
It is an example of how easily the virus moves between countries, even as governments — and particularly the Trump administration — have attempted to shut their borders. And it’s a window into how many American lives span the U.S.-Mexico border, including families who have moved freely across the region since before that line was drawn and whose movement has continued during the pandemic.
Public health issues have always straddled the border here. Texas conducts mosquito-spraying campaigns with the Mexican state of Tamaulipas during dengue outbreaks. Arizona has joint firefighting exercises with Sonora. California and Baja California have long battled a cross-border tuberculosis epidemic together. The San Ysidro border crossing, south of San Diego, is the busiest ambulance pickup point in the United States.
For years, the U.S.-Mexico Border Health Commission conducted simulations on how the two countries would respond if a pandemic settled on the border. A special procedure was created for Mexican ambulances to transfer patients to U.S. ambulances on American soil.
Then a real pandemic struck. Now, approximately half of the coronavirus patients in several California border hospitals, including El Centro Regional Medical Center, are recent arrivals from Mexico. As a result of that surge, Imperial County, home to El Centro, has a much higher concentration of coronavirus cases — 760 per 100,000 residents — than any other county in California.
“It’s amazing how this disease has taught us that borders don’t exist,” said Adolphe Edward, the chief executive of El Centro Regional. The hospital’s staff includes 60 people who cross the border from Mexicali each day to work.
About 1.5 million Americans live in Mexico, and more than 250,000 of them live in the cities just south of California. Those cities have been hit harder by the coronavirus than almost anywhere else in Mexico.
More than 300 medical personnel in Tijuana and its outskirts have been infected, according to Yanín Rendón Machuca, the head of the local health workers union. At the city’s general hospital, only a quarter of the staff remains at work. Ambulance drivers in Mexicali sometimes wait hours while hospital workers make room in hallways for patients with covid-19, the disease caused by the novel coronavirus. Some overwhelmed public clinics in the border city are no longer accepting patients.
“We see patients who have been in Mexican hospitals for two, three or four days before they cross the border and come to us,” said Dennis Amundson, the medical director in the intensive care unit at Scripps Mercy Hospital in Chula Vista, Calif.
U.S. citizens and green-card holders in northern Mexico started sharing messages and Facebook posts in groups such as “Rosarito Living” and “Expats in Mexico.” If you get sick, they say, cross the border.
So that’s what Ochoa did. He’s been a permanent resident of the United States since 1978. He retired a few years ago after a career as a truck driver in Los Angeles.
On Sunday morning, the ambulance drove him the 10 miles from the border to El Centro Regional, which was already treating 43 coronavirus patients and where a disaster response team was preparing to set up a military-style tent for overflow.
“This is where I have insurance, and it’s where there’s better attention,” he said at the hospital. The machine reading his resting heart rate bounced between 128 and 135 beats per minute.
During the pandemic, the influx of patients from Mexico has posed an unprecedented challenge. El Centro Regional normally serves a county with a population of about 180,000 residents, many of whom live below the poverty line. Suddenly, the hospital was responding to an additional community of Americans in Mexicali, thought to number 100,000 people.
When Edward posted a video update on Facebook last week explaining that his overwhelmed hospital would temporarily stop accepting covid-19 patients, he received a stream of messages criticizing him for prioritizing patients from across the border.
“Send them back to Mexico,” one person wrote.
“The border should have been closed from day one,” wrote another.
Edward, a former Air Force Medical Service Corps officer who helped lead the U.S. military’s medical team in Baghdad, tried to explain that these were Americans he was treating.
“We can pretend that 275,000 American retirees in Baja California don’t exist, but they do. Or the 35,000 military members,” he said.
The spike in cases along the border comes as California is trying to reopen. In San Diego on Memorial Day weekend, restaurants and bars were crowded with people, many not wearing masks. Medical experts warn that relaxing those rules, in addition to the cases coming across the border, could lead to a surge in infections.
“I expect Mexico to peak this month, but then as San Diego opens up, we’ll see an increase from that side as well,” said Juan Tovar, a physician chief operations executive at Scripps Mercy. “Our peak is going to depend on both of those factors.”
Among the patients who have come from Mexico in recent weeks is Patricia Gonzalez-Zuniga, a Tijuana physician who works frequently with the University of California at San Diego. Gonzalez-Zuniga and her husband were both diagnosed with covid-19 last month. Her husband’s health deteriorated rapidly.
“I have no doubt that he would have died if we had stayed in Tijuana and gone to a hospital there,” she said.
Others were U.S. citizens who took their children to Mexico for more-affordable child care. Some were Americans who had lost their jobs during the early weeks of the U.S. outbreak and went to live with relatives in Mexico to save money.
“That’s where they were infected,” said Amundson, the ICU medical director at Scripps Mercy. “And they came back to be treated here.”
Before the pandemic, more than 200,000 people per day crossed the border from Mexico to California. The Trump administration closed the border to “nonessential travel” in March, and President Trump promised to “suspend immigration” to halt the spread of the virus. But after an initial dip in entries, the pace has begun to bounce back. An average of 86,000 people per day crossed the border during the week of May 11 to 18, a mix of U.S. citizens and residents and Mexicans with legal work visas whose jobs are deemed essential.
No health screenings are being conducted at the border. When a Washington Post reporter crossed last week, an immigration agent looked at him and asked, “You’re not sick, are you?” before scanning his passport.
The Department of Homeland Security’s senior medical officer for operations, Alex Eastman, told medical professionals in Southern California this month that they should be prepared for U.S. citizens or permanent residents to continue to cross the border, including for medical treatment.
The federal government has dispatched teams from the National Disaster Medical System to the border to respond to the influx of patients. The California Department of Public Health has sent its own team. Some patients are being transferred as far north as Los Angeles to relieve border hospitals such as El Centro Regional.
Forty-eight percent of patients at Scripps Mercy in Chula Vista last week had visited Mexico in the week before they were admitted. In the hospital’s lobby hangs a painting of the Virgin of Guadalupe, Mexico’s patron saint.
“We don’t think the border should be closed, but we do think health checks and contact tracing would make a difference,” said Chris Van Gorder, the chief executive of Scripps Health, which runs the hospital. “What we don’t want is people going back and forth across the border and infecting other people.”
Last month, Van Gorder wrote a letter to Homeland Security Secretary Chad Wolf and Health and Human Services Secretary Alex Azar asking them to apply pressure on Mexico to sharpen its public health response.
“We also need the federal government to put pressure on Mexico to enforce social distancing and shelter-in-place policies as we have done in the United States,” he wrote.
On the Texas-Mexico border, the dynamic appears to be inverted. Mexican officials have expressed concern that a growing outbreak in South Texas is spilling over into Tamaulipas, which had been largely spared during the pandemic.
The United States has deported thousands of people to Tamaulipas since March. In Reynosa, Mexico, the largest city in the state, at least 16 deportees have tested positive for the coronavirus, according to Mayor Maki Ortiz. Before becoming mayor, she was Mexico’s undersecretary of health.
“Why are they continuing these deportations in the middle of a deadly pandemic, including people who are already sick and who knows how many asymptomatic people?” she said. Between the deportees and the thousands of dual citizens who cross the border every day, Ortiz worries her city will wind up importing a large outbreak from Texas.
“I say it as many times as I can on my television and radio messages: Stay in your homes and do not cross the border,” she said. “But when I look at the international bridges, I still see massive lines.”
In the nearby city of Matamoros, officials last week set up a checkpoint to question U.S. citizens crossing into Mexico and turned away some whose visits they deemed nonessential.
Some health experts say the epidemiological curves in border cities on both sides will eventually overlap.
“There are so many people crossing back and forth that it becomes one homogeneous rate,” said Arturo Rodriguez, the public health director of Brownsville, Tex. “In other words, you have three rates: the U.S., Mexico and your border rate.”
Photos by Melina Mara. Photo editing by Chloe Coleman. Graphic by Chiqui Esteban. Design by Brianna Schroer. Gabriela Martínez in Mexico City contributed to this report.
Correction: An earlier version of this article misstated Adolphe Edward’s role in the Air Force. He was a Medical Service Corps officer.