Social Science & Medicine 133 (2015) 145e152

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Cultural Health Capital on the margins: Cultural resources for navigating healthcare in communities with limited access Erin Fanning Madden University of New Mexico, Department of Family and Community Medicine, Public Health Program, MSC09 5060, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 3 April 2015

Communities struggling with access to healthcare in the U.S. are often considered to be disadvantaged and lacking in resources. Yet, these communities develop and nurture valuable strategies for healthcare access that are underrecognized by health scholars. Combining medical sociology and critical race theory perspectives on cultural capital, this paper examines the health-relevant cultural resources, or Cultural Health Capital, in South Texas Mexican American border communities. Ethnographic data collected during 2011e2013 in Cameron and Hidalgo counties on the U.S.eMexico border provide empirical evidence for expanding existing notions of health-relevant cultural capital. These Mexican American communities use a range of cultural resources to manage healthcare exclusion and negotiate care in alternative healthcare spaces like community clinics, flea markets and Mexican pharmacies. Navigational, social, familial, and linguistic skills and knowledge are used to access doctors and prescription drugs in these spaces despite social barriers to mainstream healthcare (e.g. cost, English language skills, etc.). Cultural capital used in marginalized communities to navigate limited healthcare options may not always fully counteract healthcare exclusion. Nevertheless, recognizing the cultural resources used in Mexican American communities to facilitate healthcare challenges deficit views and yields important findings for policymakers, healthcare providers, and advocates seeking to capitalize on community resources to improve healthcare access. © 2015 Elsevier Ltd. All rights reserved.

Keywords: United States U.S.eMexico border Cultural capital Latinos Healthcare access Race and ethnicity

1. Introduction “I got some [arthritis] medicine for my mom in Matamoros [Mexico]. I crossed [the border from Mexico] with my girlfriend in her truck and we put the medicine under my seat, tucked it under … You just make sure [the Customs and Border Patrol officers] can't see it. It's not a big deal. You just hide it.” e Jeanette, 23 years old Smuggling prescription drugs over the border from Mexico is one example of the many healthcare access strategies developed by Mexican American Texas border communities. In a region with high uninsurance rates, low income, large populations of immigrants and U.S. citizens who do not qualify for healthcare safety net programs, and close geographic proximity to Mexico, healthcare frequently operates “on the margins,” or in healthcare spaces outside of mainstream U.S. public and private healthcare E-mail address: [email protected]. http://dx.doi.org/10.1016/j.socscimed.2015.04.006 0277-9536/© 2015 Elsevier Ltd. All rights reserved.

institutions. There is no public hospital in South Texas and the towering private hospitals in the cities of Harlingen, Brownsville, and McAllen are often not the primary sites of healthcare access for Mexican Americans living on the U.S.eMexico border. Healthcare is frequently found in physical and social spaces that are on the edge or wholly outside of the healthcare resources and experiences of the insured middle class U.S. population. These spaces may be community health clinics, Mexican doctor's offices and farmacias, flea markets, and the homes of friends and family. It remains unclear how patients negotiate healthcare on the margins. I examine here what cultural resources South Texas Mexican American communities mobilize to navigate limited healthcare options and consider what these resources reveal about the nature of healthrelevant cultural capital in U.S. communities of color. There are several factors fueling the exclusion of Latinas/os from access to mainstream U.S. healthcare and prompt use of particular cultural resources that help with healthcare exclusion. These forces persist to varying degrees even since the implementation of the 2010 Affordable Care Act, but are still very relevant in states like Texas that did not expand Medicaid: 1) Social services eligibility

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policies (Park, 2011; Yoo, 2008; Derose et al., 2007); 2) Immigration policies and enforcement (Beniflah et al., 2013; Madden, 2013; Portes et al., 2012; Brabeck and Xu, 2010; Berk et al., 2000); 3) Border security policies (Madden, 2013); 4) Low socioeconomic status (Derose et al., 2007; Phillips et al., 2000); and 5) Cultural and linguistic barriers (Portes et al., 2012). A subset of healthcare access, access to prescription drugs, is considered in this paper because prescription drug access is vital to basic health maintenance, especially for chronic conditions. In addition, while U.S. government and pharmaceutical industry aid programs offer some help to low-income patients, many ineligible immigrants and un- and underinsured individuals still struggle with accessing prescription medication (Cunningham, 2002). Mexican Americans in particular are more likely than non-Hispanic whites to face prescription drug access barriers due to linguistic and economic issues, lack of access to insurance and social programs, and immigration policies (Chen et al., 2010). Uninsured patients like Jeanette (quoted above), as well as insured patients seek the cost advantages of Mexican medications in order to deal with prescription access problems (Calvillo and Lal, 2003). Crossborder healthcare is one of many healthcare access strategies that use health-relevant Mexican American cultural knowledge and skills. This and several other strategies will be used to conceptualize how socially, politically, and economically marginalized communities activate cultural capital to manage barriers to healthcare. 2. Theoretical frameworks: using cultural capital to manage healthcare exclusion The healthcare knowledge and strategies used by marginalized social groups bridges literature on cultural capital in medical sociology and critical race theory. I argue that the cultural capital used in Mexican American border communities to navigate exclusion from U.S. healthcare represents health knowledge that expands dominant notions of health-relevant cultural capital. Drawing on critical race theory, I conceptualize what cultural resources, skills, and knowledge marginalized communities use to navigate structural oppression in healthcare. Cultural capital describes the skills and knowledge that are considered legitimate and useful in dominant society (Bourdieu, 1986). Health research has most frequently focused on economic and social capital, but Shim (2010) adapts the concept of cultural capital, and Bourdieu's insight into how cultural practices produce and maintain social stratification, for the healthcare field. Certain kinds of cultural capital, which Shim labels Cultural Health Capital (CHC), may be used in the field of healthcare, and specifically in interactions between doctors and patients, to accrue benefits. The assets comprising CHC may change over time and across social contexts. Given the current U.S. healthcare system emphasis on consumerism, proactive patients, and self-surveillance, certain characteristics accrue more healthcare benefits than others (Shim, 2010). Modern forms of CHC include (but are not limited to): 1) knowledge of medical vocabulary; 2) efficient communication skills; 3) belief in self-discipline; and 4) ability to prioritize the future and control future outcomes. CHC moves beyond notions of health literacy and self-efficacy by recognizing how such skills and resources offer direct, indirect, symbolic, and instrumental resources in healthcare interactions. Not all patients have the forms of cultural capital that optimize “typical” doctorepatient interactions, i.e. a clinical encounter between a patient and a provider in a hospital or private practice. This may occur for two reasons: First, the ability to accrue and mobilize CHC is mediated by social position. Research on race and cultural capital shows how race, class, and other markers of social status may be reflected in CHC in ways that fuel disparities in quality of

care (Wall, 1995; Malat, 2006; Shim, 2010). Shim (2010) explains that the high value of CHC in typical healthcare encounters produces inequalities because those without these resources often are not able to optimize their healthcare interactions. A “mismatch” occurs between the CHC expectations of providers and the cultural resources possessed by patients from marginalized social positions. What is unclear from this picture is how cultural resources operate among people who are socially disadvantaged to the point that they are largely excluded from accessing these dominant healthcare spaces. What place do they have in cultural capital research? It follows that a second reason for why patients may not be able to use CHC in typical doctorepatient interactions is because some patients rarely, if ever, experience healthcare in these types of healthcare settings. The healthcare field is often imagined as these “typical” clinical spaces like hospitals and U.S. pharmacies. Lowincome un- and underinsured Mexican Americans often lack inroads to these spaces and instead use flea markets, Mexican clinics, and other healthcare spaces not typically used by insured middle class people in the U.S. This means that the healthcare field for lowincome Mexican Americans is a different terrain requiring additional types of health-relevant cultural capital not explicitly accounted for by the current concept of Cultural Health Capital. A deeper understanding of this health-relevant cultural capital is needed. Understandings of cultural resources used in marginalized groups and spaces are where I turn next. Shim's discussion of how CHC can map onto hierarchies of class and race parallels critical race theory critiques of subtle, yet pervasive forms of racism whereby institutions devalue cultural capital developed in communities of color, and revere middle and upper class white cultural capital. Through the critical race theory lens that puts race and racial oppression at the forefront of social research, scholars identify kinds of cultural capital that exist in communities of color and criticize assumptions that people of color are at a cultural “deficit” compared to whites (Yosso et al., 2009; lez, 2002; Gonza lez et al., 1995; Moll et al., Yosso, 2005; Gonza 1992). The critical race theory critique of cultural capital provides groundwork for extending Shim's concept of Cultural Health Capital into communities of color without the normative assumption that they hold little or less valuable kinds of health-relevant cultural capital. Critical race theory draws attention to ways race and racism affect social structures, which in this case is mainstream healthcare (Delgado and Stefancic, 2012; Yosso, 2005). Structures that (intentionally or unintentionally) support the “deficit view,” which uses middle class white forms of cultural capital as the standard by which to judge communities of color are examples of how structures can maintain racial bias. Deficit views blame people of color for cultural capital “mismatches” between communities of color and institutions by assuming people of color lack cultural skills (according to white standards) (Yosso, 2005; García and Guerra, 2004). If the skills and values described by the Cultural Health Capital concept comprise white middle/upper middle class standards within healthcare, it could be easy to fall into reinforcing deficit views when examining healthcare marginalization in Mexican American communities. To avoid this pitfall, I adopt a critical race theory orientation that instead argues against deficit views by identifying cultural resources used to resist structural oppression. Yosso (2005) and Yosso et al. (2009) explain how cultural capital developed in communities of color indeed has high exchange value (Yosso, 2005; Yosso et al., 2009). Yosso (2005) labels cultural resources “Community Cultural Wealth.” This concept is intended to account for the cultural resources of students of color in the education field, but also offers important insights for healthcare. Community Cultural Wealth provides an opportunity to expand

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Shim's (2010) notion of CHC, which comprises the skills and knowledge defined by dominant groups within healthcare. Community Cultural Wealth, on the other hand, is developed and activated by marginalized groups specifically in response to dominant oppressive structural forces. It is composed of six forms of capital (Yosso, 2005): 1. Familial capital refers to cultural knowledge learned through kinship ties regarding how to nurture community relationships, resources, and cultural intuition (Moll et al., 1992; Moll and Greenberg, 1990). 2. Resistant capital is skills developed to resist oppression. 3. Social capital is the network of social contacts and community resources that offer instrumental and emotional support for navigating institutions. 4. Navigational capital refers to the skills one uses to maneuver through social institutions, and especially those failing to consider marginalized communities. 5. Aspirational capital is the ability to maintain hopes for the future despite barriers. 6. Linguistic capital refers to the communication skills developed through experiences with more than one language and/or style of speaking. Four of the cultural resources Yosso (2005) defines as part of Community Cultural Wealth are also kinds of capital that constitute adaptations of Cultural Health Capital (CHC) found among members of Mexican American border communities: familial, social, linguistic and navigational capitals. These forms of CHC are particular to marginalized groups because they are activated in response to healthcare exclusion and aid in navigating “atypical” healthcare spaces. For example, in a healthcare context, navigational capital is a key skillset that may include knowing how to bring Mexican medications back across the border without problems with Customs and Border Patrol officers. This and other community-based manifestations of CHC will be discussed further in the findings section. The extensive critical race theory literature on cultural capital and new research on Cultural Health Capital encourage attention to health-relevant cultural resources in marginalized communities of color. Notable preliminary efforts in this vein include research on Transnational Cultural Capital (Grineski, 2011) and coping strategies (Portes et al., 2012). Portes et al. (2012) examine strategies for coping with immigrant marginalization in the U.S. healthcare system. Coping strategies may include informal medicine like curanderas/os, or seeking “grey medicine” from unlicensed health professionals trained abroad. Grineski (2011) describes the concept of Transnational Cultural Capital, or the resources among Northern TexaseMexico border residents that mixes U.S. and Mexican cultural skills and knowledge to access cross-border healthcare. Coping strategies and transnational cultural capital provide some indication that different sets of community-level healthcare knowledge and skills may exist, and these lie largely outside the healthcare fields of insured U.S. citizens. Such differences necessitate reconsideration of the types of cultural skills and knowledge that facilitate healthcare access in marginalized settings. The empirical research presented below provides further insight into the complex ways people actively respond to marginalization, both pre-Affordable Care Act health system barriers, as well as postAffordable Care Act issues that persist especially in states that did not expand Medicaid. 3. Data and methods This research draws on 12 months of ethnographic field research

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conducted in two waves over 2011e2013 in the South Texas counties of Cameron and Hidalgo along the U.S.eMexican border. Data are composed of over 100 h of in-depth interviews with 59 participants and 10 h of observation at U.S.eMexico border checkpoints, U.S. and Mexican pharmacies, and U.S. and Mexican clinics and doctor's offices. With the help of 3 local Spanishspeaking research assistants I conducted semi-structured interviews with 15 healthcare professionals working with community health centers and 44 patients or caregivers who buy prescription drugs. Of the patients and caregivers, 8 are or have recently been undocumented immigrants, 1 is an authorized immigrant with a temporary visa, 3 are permanent residents, 5 are naturalized U.S. citizens, and 27 are U.S-born citizens, 4 of which have unauthorized immigrants in their immediate family. 39 patients and caregivers identify as Mexican, Mexican American or Hispanic, 4 as non-Hispanic whites, and one as Native American. 26 patients/caregivers are women and 18 are men, and their ages range from 18 to 73 (80% of participants are between 30 and 60). In the sample 19 patients lack health insurance, and the vast majority of all participants have at least one friend or family member without insurance. Most patients and caregivers are working class, working poor, or low-income: 10 live on public assistance, 3 are over 65 and retired, 3 are unemployed, 5 are students, 4 are selfemployed, and 16 patients and caregivers work in moderate to low-wage hourly positions. The names of all participants discussed have been changed to pseudonyms. Recruitment was based on a theoretical sampling frame, or recruitment for the purpose of theory development. My research assistants and I recruited healthcare professionals from online clinic directories (7 professionals) and from the author's social networks (8 professionals) based on their answers to simple questions about their ability to offer substantive feedback regarding the healthcare issues of their patients. Patients and caregivers were recruited using three strategies: recruiting from the research team's social networks, “cold approaches” and snowball sampling from the social networks of cold approaches (immediate family and close friends). Recruitment was based on the potential participants' answers to basic questions about their or their close family members' ability to access healthcare in the U.S. and in Mexico. Just under half of the patient/ caregiver sample was recruited by approaching unknown individuals in community clinic waiting rooms and in public downtown areas. Roughly one third of the patient/caregiver sample was recruited from relatives and close friends of cold approach participants, and the remaining participants are individuals from the research team's social networks (e.g. neighbors and friends). This latter strategy was important for recruiting unauthorized immigrants, who required higher levels of trust with the research team before agreeing to participate due to deportation fears. Early recruitment efforts did not target immigrants, but later recruitment did seek immigrants of any status (unauthorized, naturalized, etc.) in order to understand unique healthcare barriers and strategies not shared by U.S.-born participants. The University of WisconsineMadison IRB approved all study activities. Participants were not recruited on the basis of race, ethnicity, or socioeconomic status at any stage of the research process. The predominantly Mexican American and low-middle income status of the sample reflects the larger demographics of South Texas border areas, where 89% of residents are Latino/a and 34% of the population lives below the poverty line (U.S. Census Bureau, 2009). The guiding methodology for data collection and analysis is constructivist grounded theory (Charmaz, 2006), which draws on Glaser and Strauss' grounded theory methodology (1967). Constructivist grounded theory is a systematic approach to qualitative research emphasizing building theories through

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simultaneous data collection and analysis. As I collected interviews and field observations, these data were coded into the most frequent and significant themes (Charmaz, 2006). Analysis also included “memoing,” or writing short analytic documents, to further refine theoretical explanations of the field processes. While the preliminary interview guide drew sensitizing concepts from research on cross-border healthcare (e.g. Bastida et al., 2008; Byrd and Law, 2009), subsequent guides focused on emerging themes surrounding prescription drug access strategies. 4. Findings: mobilizing Cultural Health Capital in marginalized healthcare contexts When barriers to U.S. healthcare, and prescription drug access in particular, deter patients and their families from seeking care through standard channels like private hospitals and pharmacies, then community strategies, knowledge, and resources are triggered to seek alternative routes to basic prescription drugs. Communitybased forms of Cultural Health Capital (CHC) underlie healthcare strategies like: 1) using social networks; 2) knowing how to access prescription medication in Mexico; 3) knowing illicit means for obtaining prescription drugs; and 4) finding and enrolling in community clinics and prescription drug programs. These four common strategies for prescription drug access reveal how cultural resources developed in Mexican American border communities are used to manage health on the margins. 4.1. Using social networks Patients may draw on a variety of resources in their social network in order to manage barriers to prescription drugs. Social networks used in healthcare strategies most often include immediate family and close friends/neighbors, but may also include acquaintances and more distant community members like church outreach workers. Here, patients use social and familial capital such as friends' and family's knowledge, money, Spanish or English language skills, as well as citizenship status to facilitate access to prescription drugs. While all Mexican Americans in the sample described relying on kinship ties or being relied upon to facilitate prescription drug access, recent and unauthorized immigrants tend to rely exceptionally hard on social networks. Louria is young U.S.-born Latina woman in her late 20's who works as a line chef and cares for her elderly undocumented grandmother, who we discuss at length in our interview. Louria also has two young children and is the only adult in her household who speaks English. When I knocked on her door for our prearranged interview Louria's mother reluctantly answers and tries to wave me away as I stumble over an explanation of who I am. Through the screen door I see Louria rush from a back room rapidly speaking to her mother, “it's ok, it's ok, it's for me.” Louria later explains that her mother's first instinct seeing an Anglo-European person at the door was that I was with “la Migra” (Immigration enforcement) or a collection agency. Louria has a steady job and makes well over minimum wage, but supports her whole familydmother, grandmother, and two childrendon this income. The family lives in a low-income neighborhood in the city of Brownsville that only recently received paved roads, although families have been living in the neighborhood for decades. As we discuss how Louria essentially coordinates everyone in her family's healthcare, she describes a particular struggle several months before our interview when she needed to identify healthcare and prescription programs for her grandmother. Despite uncertainty about how to get prescriptions for an undocumented family member, Louria uses her English language skills and experience with Medicaid to help her grandmother.

“My grandma is so old and she gets sick a lot. I honestly didn't know what to do with her because she was getting sicker. She has a bad heart and high blood pressure, so I know she needed medication, but without insurance or [immigration] papers it's hard. There's not much help for her, really. But I did find a clinic nearby by calling the church program that helped me with Medicaid when I was pregnant … My grandmother doesn't speak English well, so I knew it would be easier for me to do it … This was all after she had a stroke and we went to the ER that I realized I gotta help this woman. It's on me … it took me a while, but I finally found her a [community] clinic that helps her with doctor's visits and getting her on her medicine … They put her on generics and help her pay for it.” Louria's experience with her grandmother illustrates the kind of help immigrant patients may receive from their kinship ties. Given Louria's grandmother's unauthorized status, she does not qualify for Medicare or Medicaid, which offer prescription drug programs for low-income elderly people. Neither Louria nor her grandmother can afford insurance on the private market. Thus, Louria's grandmother relies on her social network, and specifically Louria, for healthcare help. Louria provides her grandmother overlapping kinds of CHC. By taking on the informal home care her grandmother needs, Louria offers familial capital, and by seeking formal healthcare resources for her grandmother, she provides her grandmother with social capital. Louria also mobilizes her English language skills and knowledge of local institutions to contact aid organizations. Louria's navigational and linguistic capital play central roles in managing her grandmother's exclusion from typical avenues for accessing prescription drugs. Some participants also rely on social networks for access to prescription drugs by sharing medications for similar conditions. This often occurs in families of mixed immigration status, where one or more U.S. citizens with access to health insurance or Medicaid/Medicare share their prescription drugs with a friend or family member who cannot afford or qualify for coverage. Rosa and Juan, a married Mexican American couple in their late 50's, share medication prescribed to Juan, who is a U.S. citizen enrolled in Medicare and Medicaid. Rosa, however, is an unauthorized immigrant without healthcare or prescription drug coverage. Rosa explains the last time she and her husband shared medication, “I fell down from where we used to live, a 2 story home. I suffered dizziness and fell. Then I hurt my arm falling [pointing to her right arm]. I went to the hospital and they never treated me because of not having money [to pay for care]. I spent all day there and then I had to come back [home without any care] and so I took my husband's medicine for pain.” Rosa uses Juan's prescription painkillers in order to manage her injury after being turned away at a local private hospital for lacking insurance or a down payment. Drawing on her husband's prescription resources, Rosa mobilizes social capital to receive drugs despite exclusion from a formal healthcare institution. Rosa's case is a very clear example of how healthcare strategies using nondominant kinds of CHC, here social capital, are activated in response to exclusion from mainstream healthcare resources like emergency rooms. Using social networks to facilitate prescription drug access is also a feature of following strategies for navigating healthcare on the margins. Although many times patients themselves devise ways of seeking prescription medication despite lacking health insurance and other resources, often family and friends play a role

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in nurturing health and navigating institutions. The common nature of accounts like Rosa's and Louria's in the study illustrate how familial and social capital are crucial parts of CHC in South Texas Mexican American communities. 4.2. Seeking prescription drugs in Mexico Given relatively higher prices of U.S. pharmaceuticals (Fullerton and Miranda, 2011) and U.S. healthcare access barriers identified in Latina/o immigrant health research, many South Texas border residents (insured and uninsured) travel to Mexico for prescription medication (Su et al., 2010). Two policies complicate the widespread local practice of seeking medications in Mexico: pharmaceutical importation policies and passport policies. Importation policies outlined by the U.S. Food and Drug Administration and enforced by Customs and Border Patrol require a U.S. physician's prescription for most drugs (even non-narcotic basic health maintenance drugs) and limit the amount and types of importable drugs (21 C.F.R. x 1301.26 (2004); CBP 2012; FDA 2011). Immigration control policies requiring passports at border ports of entry add costs to crossing to Mexico for prescription drugs ($55 per adult and $40 per child for a passport card). Passport policies also mean border crossing for prescription drugs is nearly impossible for unauthorized immigrants living in Texas who lack appropriate visas to reenter the U.S. after such a journey (Madden, 2013). Mexican Americans in South Texas employ a range of strategies that use familial, social, navigational, and linguistic capital to either follow or undermine border policies. Mari is a 56-year-old unemployed permanent U.S. resident from Mexico who has trouble affording drugs for depression and diabetes in the U.S. She explains her process of determining whether she will manage this problem by going to Mexico, “the pills I buy in Matamoros because they are a lot cheaper over there. Here [in Texas], the pills cost me $13 for a month supply. Over there they cost me $4.99 for 3 months … in the newspaper El Heraldo are the prices for medicines at Garcia's [Farmacia in Mexico] and so I check there for the name of my medicines and I go and buy them.” Garcia's is a large department store in Matamoros, Mexico just one block from the border bridge connecting to downtown Brownsville, TX. The second floor houses a smoky restaurant decorated in mid-century modern touches, a tourist shop full of pottery and rugs, and a pharmacy where dozens of participants in this research often purchase their prescription drugs. Mari uses linguistic capital to identify cost savings in Mexico using Spanish language newspapers. She then again uses linguistic capital to ask Mexican pharmacists at Garcia's whether her prescriptions can be imported to the U.S. legally in order to avoid confrontation with Customs and Border Patrol officers, “I ask at the pharmacy if I can cross [the medicine] before I go so I won't have a problem at the bridge.” Participants largely cross the South Texas border by foot or by a personal vehicle. Before reentering the U.S. they must wait in a line of cars/people (ranging from a few dozen to a couple hundred depending on time of day) in order to be screened by a U.S. Customs and Border patrol officer. The officer asks for identification and scans the passport/identification documents while questioning the border crosser. Questions typically include inquiries about why the individual is crossing the border on that day and what they are bringing with them. Officers may further ask to look inside bags and pockets, or ask more in-depth questions. Mari's use of Mexican newspapers and her conversations with Mexican pharmacists are examples of navigational capital used for the purpose of avoiding problems during questioning by U.S. border officials: by seeking information about prices and importation to the U.S., she is better able to navigate transnational prescription access. She does not have a computer, and detailed policies

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regarding prescription importation are not posted at the border bridges. Mari thus uses overlapping forms of linguistic and navigational CHC to seek this detailed information from Mexican pharmacists. Similar to Jeanette, whom I quote at the start of the paper, other participants have a more relaxed view of prescription drug importation than Mari. Instead of using CHC to follow the rules better, these participants use CHC to undermine border security regulations by simply hiding (and not declaring) the Mexican prescription drugs they are transporting across the border. Jeanette, and many other young U.S.-born Mexican American participants, use navigational capital in this endeavor; specifically, knowledge of how to avoid surveillance by Customs and Border Patrol officers. Petra, a 26-year-old U.S.-born citizen and homemaker describes concealing several months of Mexican birth control pills for herself and her cousin into a pocket in the lining of her purse and into the waistband of her jeans before crossing by foot to the U.S. Petra's method is generally the same each time she does this: she takes the pills out of their boxes and hides the thin foil packets before walking across the congested roads that lie between the Mexican pharmacy and the international bridge. She explains that this is easy, but that she always makes sure that the hiding is done before she enters the immediate bridge area where U.S. officials might see her stash pills away. Petra has been crossing to Mexico for medications with members of her family for as long as she can  tone, “Just shove [the prescriptions] remember and says in a blase somewhere [CBP agents] won't look, act normal, and walk across like you always do.” She adds, “It's probably good to have, like, some chips or something else that you bought so when they ask if you bought anything you have something to show. But really, it's pretty easy to get away with it … People I know do it a lot.” Petra illustrates her ability to use navigational capital to bring back prescription drugs to the U.S. without going through the trouble of explicitly declaring them to Customs. She learned ways of hiding Mexican prescription drugs and how to “act cool” from kinship ties as well, illustrating cultural intuition that composes her familial capital. Petra is also one of the only people in her family with a passport card that she bought to “get less hassle from border patrol” when she crosses from Mexico. On the whole, those with passports have an easier time crossing the border than people with only birth certificates. Jeanette, who uses a U.S. birth certificate when border crossing says, “Sometimes they give you trouble, but they'll just hold you for an hour or two. They gotta let you in eventually!” Petra's passport card provides her with an additional source of navigational capital, as well as social capital to her family, by allowing smoother and less time-consuming border crossing and prescription drug importation. Even though Petra is relatively at ease with using navigational and familial CHC to facilitate cross-border prescription drug access, this still seems more difficult than staying in the U.S. to buy birth control. I wonder in what ways Petra and her cousin are excluded from U.S. healthcare, especially given the numerous community clinics within a few miles of her home. When I ask why she prefers to cross birth control pills from Mexico versus going to U.S. clinics, Petra responds, “What's easier: going to those places and … paying $7 per [monthly] pack and having to go back when the prescription is up? Or walking to Mexico, paying $2 per [monthly] pack for as many packs as you want whenever you want? And I can get it for me and [my cousin].” Petra learned to do this kind of international cost comparison from friends and family who do the same for their own medication,

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illustrating use of social capital to navigate the binational healthcare field on the South Texas border. While the cost difference may appear small, saving ten dollars per month between Petra and her cousin is crucial income for their family. Finding ways to reduce spending on prescription drugs is an important skill that helps Petra manage her family's budget. Petra and Jeanette's prescription drug importation practices may be considered “smuggling” by Customs and Border Patrol standards. However, in Mexican American border communities the illegality of these practices is deemphasized. The most common drugs participants cite importing are birth control, antibiotics, and drugs to treat arthritis, high blood pressure, and diabetes. Participants in this study do not cite importing prescription narcotics without declaring them to Customs officers. Of course, there are both legal and health risks that accompany purchasing and using prescription drugs for other people and without physician supervision. It is nevertheless important to consider how many South Texas Mexican Americans frame importing non-narcotic prescription drugs for friends and family as a necessary and fairly mundane practice. 4.3. Employing illicit means Many participants, especially unauthorized immigrants who cannot themselves travel to Mexico for pharmaceuticals, rely on illicit means for obtaining prescription drugs. Illicit means may include “smuggling” medications from Mexico, sharing medications not prescribed to the user, and buying medications on the informal market. Focusing on the latter, many participants cite occasionally buying Mexican medications from small stands at the open-air weekend flea markets that exist in almost every town in South Texas. The sale and purchase of these drugs is illegal and risky, but for many consumers, legal considerations and safety concerns about drug interactions or the quality of medications do not outweigh the cost savings of cheaper drugs or the health consequences of not taking drugs altogether. Ana María, a 53-year-old undocumented homemaker from Mexico living in Alamo, TX since 1998, frequently uses the flea markets in South Texas to get prescription drugs. She says, “I have never been to Mexico to see a doctor or anything since I came to the U.S., but I do get Mexican medications from the pulgas, the flea markets … Someone else brings it from Mexico and sells it at the pulgas. I will buy these drugs for infections and stuff, for my girls and whatever is needed.” When asked why she used this strategy for getting her diabetes prescriptions instead of “typical” routes like a pharmacy Ana María explains, “I have money problems. I was using a clinic [in Alamo] and paid $40 for just the medical consultation and had no money left for medicines because on top of that we have to pay rent.” Ana María lives in a small two-bedroom trailer with one of her daughters and her husband. Her home is modestly decorated and she wears no jewelry, not even a wedding ring. These visual markers of financial hardship support her mentions throughout the interview that money problems are significant in her life due to the fact her whole family lives off her husband's meager disability checks. The flea markets offer a cheaper (although largely unsupervised) way for Ana María to buy her diabetes medications, as well as any other medicines she needs. I frequented local flea markets in South Texas during my fieldwork, but had never seen anything medical for sale other than old crutches and color contact lenses. When I asked a friend, Jorge, who was born and raised in South Texas why I never saw any prescription drugs he said, “Well, you need to know who to ask. And you need to ask in Spanish. Plus they might be worried you're the FDA or something since you're white.” Jorge highlights that this illicit prescription drug access strategy is not necessarily available

to non-Mexican Americans. Knowing who to ask, and how, is learned through familial capital and requires linguistic and navigational capital that is available to South Texas Mexican American communities. Whiteness is often associated with law, immigration, and other types of enforcement agencies. The flea market strategy is an important illicit access avenue for many participants, however, like cross-border strategies, it is accompanied by risks. The majority of healthcare providers participating in this study cautiously defend illicit access strategies for those patients who have few alternatives but temper their support by expressing fears over potential health complications. Illicit means are not an ideal healthcare access strategy in the eyes of either providers or patients and caregivers. However, given cost barriers to alternative options, using local forms of CHC to get prescriptions at flea markets remains an instrumental prescription drug access strategy for Mexican Americans. 4.4. Navigating community medicine and aid programs For Mexican American patients seeking non-illicit access to cheaper prescription drugs in the U.S., there are prescription aid programs in which they may seek enrollment. Pharmaceutical companies, community clinics, and the Texas Department of State Health Services manage programs to make reduced cost prescription drugs available to low-income patients. Patients and caregivers work with healthcare professionals at community organizations, especially community health clinics, to enroll patients into assistance programs. But many prescription aid programs, including the Department of State Health and pharmaceutical companysponsored aid, require U.S. citizenship, excluding many lowincome immigrant patients. Stephanie Guerrero, the director of a small primary care clinic serving uninsured patients in South Texas, describes how excluding immigrants from pharmaceutical assistance programs places her clinic in a difficult position, “Our case manager is very helpful in getting patients on prescription assistance programs. Because there's a lot of prescription assistance programs here … But a lot still don't accept applications for people without a social security number. So, when it comes to things like that we have to try hard to make partners with the pharmacists in town or the doctors who may have donations of medications.” Requiring a U.S. social security number bars eligibility from many immigrants. Immigrant patients are especially challenging for community clinics because clinics have to piece together alternative means for obtaining prescription drugs. Considering such eligibility issues, many low-income immigrants employ one of the other three strategies discussed, although some do find inroads to aid programs. Navigational capital on the part of the patient, or their social network (as is the case for Louria's grandmother discussed earlier), is needed to find community clinics and determine which offer prescription programs for unauthorized immigrants. Especially for unauthorized immigrants, but also for any patients lacking insurance and unwilling to travel to Mexico or use illicit means, using CHC to navigate community clinics and prescription aid programs is crucial for accessing drugs. 4.5. Limitations of CHC in marginalized communities The use of CHC described in the previous strategies is often successful in delivering basic health maintenance drugs to patients, but it is not a panacea. Problems that can arise from strategies

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described in these findings include: improper pharmaceutical use, exhausting resources in social networks, and unreliable access. These may be due to participants not having enough (or the right kinds of) CHC to manage healthcare in any context, including the marginal spaces described above. These shortcomings indicate that the CHC in Mexican American border communities, like dominant forms of CHC, may be unequally distributed and offer differential utility depending on factors like social network composition, citizenship status, experience with U.S. bureaucracies, and bilingual language capabilities. Future research should focus on understanding how CHC in marginalized communities is developed and differentially distributed. For the most part, participants agree that these local strategies for accessing prescription drugs are inferior to mainstream avenues for prescription drug access like health insurance with low or no co-pays or enrollment in Medicaid and Medicare. Serious structural barriers to mainstream healthcare resources necessitate the use of navigational, social, linguistic, and familial CHC. As long as healthcare marginalization persists, the CHC developed in marginalized communities offers valuable resources to low-income and immigrant communities of color for accessing healthcare. But recognizing CHC in marginalized communities is not a call to divert attention from addressing structural inequities within healthcare. 5. Conclusion The four strategies described in this paper for accessing healthcare, and the kinds of capital employed to execute such strategies, suggest a broadening of Shim's (2010) notion of Cultural Health Capital (CHC). This is not to say that Shim's formulation of CHC is incorrect; instead, CHC provides a crucial theoretical contribution on which to build understandings of health-relevant cultural capital in communities often excluded from the U.S. healthcare system. The CHC concept accounts for cultural skills that aid in “typical” doctorepatient interactions. I expand CHC in two main ways: First, I use critical race theory contributions to cultural capital research in order to highlight how CHC can be activated in response to oppressive structural forces in healthcare, such as limited access to insurance, private and public hospitals, Medicaid, and Medicare. Second, I extend the concept of CHC into “atypical,” or (perhaps better described as) marginalized healthcare spaces like community clinics and informal healthcare markets. I draw on Yosso's (2005) concept of Community Cultural Wealth, and its attention to rejecting deficit views by identifying health-relevant cultural resources in marginalized communities. The healthcare strategies used in these communities require cultural resources that are largely different from the resources necessary to navigate dominant healthcare resources. The resulting expanded articulation of CHC bridges medical sociology and critical race theory perspectives on cultural capital, and recognizes both community resiliency and the limitations of efforts to counteract marginalization. Expanding the CHC concept into marginalized healthcare spaces may provide insight into why marginalized social groups have worse health than privileged social groups. A major impediment to reducing health inequalities is that low-income communities of color lack dominant forms of CHC valued by physicians and health institutions (Shim, 2010). But communities lacking dominant CHC also develop their own forms of CHC that need to be added into the equation. This paper suggests that health inequalities may also be tied to the variable success of local community-based CHC. In short, it could be that health inequalities are fueled by both differences in mainstream CHC and the ability of marginalized communities (and individual community members) to make up for healthcare exclusion using local forms of CHC.

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This research has practical implications for healthcare institutions and providers, advocates working with low-income and/ or immigrant communities, and policymakers in the U.S. and in the international community. First, this research reinforces the critical race theory orientation in healthcare social justice work. Advocates and minority-serving healthcare institutions should not only focus on the lack of dominant cultural resources within marginalized communities. Instead, capitalizing on existing community CHC could provide avenues for immediate healthcare access improvements among marginalized populations within the confines of current structural constraints. This is not only a strategy for U.S. advocates since international immigrant healthcare research shows , fear of institutions and immigration enforcement (Larchanche 2012), poverty (Jones, 2012), and legal barriers to healthcare (Willen, 2012) are not specific to the U.S. Receiving countries across the world erect barriers to healthcare and many immigrants develop their own localized forms of CHC to manage exclusion. Capitalizing on these resources may take many forms. For the South Texas communities discussed above, healthcare providers at community health centers could capitalize on the use of flea markets as healthcare supply sites by establishing mobile clinics and prescription drug information booths at these weekend events. This is an opportunity to intercept patients who would otherwise buy prescription drugs on the informal market and provide them with drug interaction information and offer prescription drug program enrollment assistance. One of the benefits of capitalizing on CHC is that does not always require large-scale structural changes in order to improve healthcare access. But in some instances exploiting local CHC for health improvement may require policy change. This research is also an appeal to policymakers to consider how healthcare laws and regulations not only exclude marginalized groups from healthcare but also can bruise the ability of community CHC to counteract exclusion. The ethnographic case study used in this research calls into question the value of U.S. policies regulating prescription drug importation in particular. South Texas Mexican American communities rely on Mexican prescription drugs. Policies limiting the amounts of prescriptions, requiring a U.S. doctor's prescription, and forbidding importation for another person's use inhibit an important source of healthcare for border residents. The motivation for such policies is ostensibly patient safety (21 C.F.R. x 1301.26 (2004); CBP 2012; FDA 2011), but with few alternatives for affordable prescription drugs policymakers must reconsider whether prescription policies truly prioritize health. Especially considering Affordable Care Act policies that further exclude many immigrants from healthcare resources by barring them from purchasing insurance through state exchanges, transnational healthcare is likely to remain a strategy used in Mexican American border communities. Acknowledgments Thank you to my research assistant, Rene Cardona, and to Laura Senier, Cameron Macdonald, Pam Herd, and Jane Collins for their comments. Additional thanks are owed to the anonymous reviewers for their helpful comments and suggestions on the manuscript. Finally, my deepest gratitude for assistance from Jose, Castillo, Victor, Brenda, Stephanie, Joe, Mark, and Mike during my fieldwork. References Bastida, E., Brown, H.S., Pagan, J.A., 2008. Persistent disparities in the use of healthcare along the US-Mexico border: an ecological perspective. Am. J. Public Health 98, 1987e1995.

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