In late spring 2024, Dr Brian Elmore was working out of a mobile clinic, providing medical treatment to migrants in Ciudad Juárez, just south of the US-Mexico border wall. One of his patients, a Venezuelan man with a fractured arm and a detached left chest from his sternum and clavicle, told Elmore that Mexican immigration officials broke his arm when he first got to town, and that rubber bullets fired by Texas national guardsmen had caused his chest injuries.

The man somehow had managed to fashion a shoddily made splint for his arm, but his chest would require surgery. When an ambulance arrived, the criminal group that controlled the riverine area refused to let him leave. The Texas guardsmen looked on from the US side of the river. “It was heartbreaking,” Elmore said of the spectacle.

Two years prior, Elmore had begun his medical residency in El Paso, Texas, at the region’s only level 1 trauma center. The city sits at the western tip of Texas in the Chihuahuan desert, with the Rio Grande marking its border with Mexico. To Mexicans, it was known during the late 19th and early 20th centuries as the Ellis Island of the south-west. These days, migrants continue to arrive from Latin America and around the world – a fair number require immediate medical aid.

Day and night, Elmore witnessed all manner of injuries. “At the hospital I was working at, anybody could get any emergency care they needed,” he said. “A few blocks away, in Juárez, there was a huge population of displaced migrants and refugees with limited or no access to care.” The disparity struck him as unnecessary and cruel. After a few stunted efforts to organize health services for migrants in fall 2022, Elmore co-founded the Hope Border Institute to attend to the medical needs in Juárez as best they could.

By this point, trauma doctors had already begun to describe the rash of severe injuries as a public health crisis. People were falling from the border wall, fracturing legs, severing spines, and suffering brain damage. They were drowning in the Rio Grande canals and suffering deep lacerations from razor wire. In the surrounding desert, they were found suffering from dehydration and heat exhaustion. El Paso did not typically rank among the most dangerous border crossings in the world, yet during one brutal stretch from early 2023 to August 2024, it was the deadliest section of the deadliest land migration route in the world.

As medical research identified enforcement barriers as the cause of injuries and deaths, trauma doctors who worked in border hospitals called attention to the US border policy of deterrence. First deployed in El Paso under President Bill Clinton with Operation Hold the Line, the policy is designed to funnel migrants into the most inhospitable environments possible so that crossing becomes unthinkable – not that it has stopped desperate people from trying.

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When Donald Trump took office in 2017, he promised to expand the border wall between the US and Mexico (a “Trump wall”) to deter crossings, among other escalatory measures. More recently, the administration raised the stakes by declaring a national emergency on the border, which allowed for the deployment of federal troops without congressional approval. Trump’s One Big Beautiful Bill Act, passed by Congress last July, will invest $170bn in immigration enforcement, including $46.5bn to complete the wall. But arguably the most significant piece of funding – roughly $30bn over four years – has already begun to supercharge Immigration and Customs Enforcement (ICE) efforts to arrest and deport immigrants in all corners of the nation. What that has looked like from the street is a series of vicious clashes between federal agents and protesters; at least eight people, including at least two US citizens, have died in dealings with ICE so far in 2026. The great irony of this influx of punitive spending is that migrant arrivals had fallen off their peak before Trump returned to office. His strict immigration policies have led to an even sharper decline. There are also far fewer border-related injuries.

As Elmore’s residency wound down in late summer 2025, he took stock of all he had seen and learned. He had come to believe that a physician’s responsibility was not confined to the exam room, but rather extended to the social and political pathologies that manifest as illness and disease in their patients. In his free time, he cared for migrants on the streets of Juárez and wrote articles about the humanitarian and public health crisis he was witnessing. On the border, ordinary people were doing extraordinary things to help migrants, and he saw it as a moral obligation to get involved.

By summer’s end, he was leaving a city with fewer migrants, but one that felt under occupation, with Black Hawk helicopters flying overhead and Stryker combat vehicles on the horizon. Attention had shifted away from the border, but Elmore says it will eventually return.

A more dangerous wall

Elmore had not been a particularly serious student at Clemson University, but he was curious about the world, after being raised on his father’s stories of combat in Iraq. In 2012, Elmore spent a couple of weeks backpacking around the Kurdish north. One conversation with a Syrian refugee still replays in his mind. They discussed the plight of those who had fled the war-torn country when the man asked him: “What are you going to do about it?”

While his classmates in the biology department were making plans to study medicine, he joined the Peace Corps. He was assigned to Sierra Leone in 2014 to teach farmers how to raise fish for food and extra income. After two months, Ebola broke out. As doctors were rushing into the country, Elmore, along with all other nonessential staff, was evacuated. A feeling of helplessness washed over him. Medicine, he began to realize, could be a means to address social inequities.

Back in the states in 2018, he enrolled at the University of South Carolina school of medicine (MUSC), where he founded the MUSC asylum clinic. Physicians and medical students provided forensic examinations to asylum seekers, documenting evidence of torture or trauma, which can improve the success rate for asylum. In the classroom, he learned to be a doctor. On the border, where he was matched for his residency, he discovered the kind of doctor he wanted to be.

Mere weeks on the job at the El Paso emergency room, a group of migrants was rushed into the emergency department. They had been chased by US Border Patrol agents and crashed – not an uncommon occurrence. Most were taken to resuscitation bays when another patient arrived, and a nurse called for a doctor. Now it was Elmore’s turn. “What I remember most was how young he was, and I think how nervous I was taking care of somebody who’s had a traumatic injury like that,” he recalled. Still in his early 30s, Elmore was barely older than his patient. The man had a few broken bones, nothing life-threatening, but still, it was nerve-racking. Elmore fell back on his training and narrowed his focus to the patient in front of him.

But he went further than that. He got to know his patients’ stories: who and what they carried with them or left behind, the sacrifices made to reach the border, and the trauma endured. When he could, he contacted family members to let them know their loved ones were safe. Among the possessions of his first border wall patient was a rosary, a passport, a prayer card, and a photo of her loved ones.

“At some moment before climbing the wall, she would have been forced to choose the most important things for her to carry,” he said. “You fall off the wall, and all of a sudden you’re in this huge hospital surrounded by doctors and nurses and law enforcement; everything that’s happening to you is such a shock to the system.” Under these circumstances, carefully chosen personal items can be grounding.

In these situations, Elmore learned that a too-narrow focus risks overlooking the pathology affecting the larger group of patients. The often-told public health parable, credited to medical sociologist Irving Kenneth Zola, illustrates the point. An internist, standing at a riverbank, pulls a drowning person from the water. Soon enough, however, another drowning person appears, and then another, and yet another. The internist, overwhelmed with the immediate need, has no time to investigate the upstream social conditions that might explain why so many are in the river. Elmore, facing just such a dilemma, drew inspiration from Paul Farmer, the renowned physician and medical anthropologist whose work in impoverished countries focused on social justice. To serve his patients, Elmore believed it was his responsibility to understand the upstream conditions driving his patients to the emergency room.

These experiences forced him to work harder as a physician; they also convinced him that the pathology of his patients was political. “These are conscious political decisions to make the border as violent as possible,” he said. “If our goal as physicians is to prevent suffering, then we have to address the cause of the suffering.”

Even if the bodily trauma that occurs so frequently along the US-Mexico border were accepted as a threat to public health, there is a disturbing reality that injuries and deaths are a useful deterrence, and perhaps even intentional. The best example of this is Trump’s “big, beautiful” border wall built during his first term in office. Back in 2019, Rodney Scott, then the Border Patrol chief for the San Diego sector, shared wall prototypes with migrant advocacy groups, which, according to one local advocate, were all 30ft (9 metres) tall. Scott told them the agency had conducted psychological research and found that at that height, a person is more likely to lose their balance and fall.

“He said it in a tone like he was excited,” said Lily Serrano, one of the advocates at the unveiling. She jotted down the extraordinary admission in her work journal, then joined the chorus of outraged objections. She couldn’t prevent the wall’s construction any more than border agents could keep people from climbing it. A coat of black paint is being applied to make the supposedly impenetrable structure too hot to climb. Scott is now the commissioner of CBP, a reward for overseeing the project. Border Patrol told me the idea that it intentionally designs border barriers so that people fall is blatantly false. “The wall is designed to secure our border and keep illegal aliens OUT of our country,” the agency said.

There is little evidence that a taller wall is any more an effective deterrent than a shorter one. Illegal border crossings actually increased for several years after the 30ft wall was built. “What it has done is impose a pretty large burden on border trauma centers having to deal with these major injuries, and it’s imposed a bunch of costs on the hospitals and ultimately on taxpayers who have to pay for that,” said Jay Doucet, a trauma surgeon at UC San Diego Health.

From 2020 to 2022, the sheer volume of wall injuries in San Diego created a backlog that forced the prioritization of brain surgery over other procedures, and hospitals footed the $72m bill. The two-year period starting in 2021 cost the University Medical Center in El Paso $22.2m to care for its migrant patients. To Doucet’s mind, the collateral cost of the wall points to a design that was not fully considered. Then, quoting the famed American business theorist W Edwards Deming, he added: “Every system is perfectly designed to get the results it gets” – suggesting the outcome was entirely predictable.

In July 2023, Alexander Tenorio, a neurosurgeon at University of California San Diego Health and author of many of the reports, testified before the US House committee on homeland security, subcommittee on border security and enforcement. He spoke about his research on traumatic brain, facial and spinal injuries, and on what drives his patients to migrate. “As the son of a father who escaped violent threats in his home town as a teenager and now a first-hand witness to these stories, I can assure you that these people that I care for are searching for the same things that my parents did,” Tenorio told committee members.

Doucet and Tenorio have pushed for more resources to be allocated to hospitals and, importantly, that the construction of taller border walls stop. They sought out allies among elected officials across the southern border and the Congressional Hispanic Caucus to champion their cause, to no avail. “Everybody’s very concerned when we talk to representatives at the municipal, county, state, or national level, but the issue is essentially radioactive, and nobody really has any solutions or wants to propose any,” Doucet told me ahead of the 2024 presidential election.

Among the hundreds who have fallen from the towering wall near El Paso and then been taken to the hospital where Elmore worked is a twentysomething Mexican man named Juan. When he set out from central Mexico in 2023, his job prospects were bleak, and Juan wanted to get ahead in life. There were any number of jobs waiting for him in New York if he could get there; it had not occurred to him that he might be crippled in the process. Yet dangling from a rope atop the border wall, Juan lost his bearings and leapt to the ground. He lay there for hours in blood-soaked pants, his leg snapped at the ankle. As the hours dragged on, he wondered if he would die on the ground beside the border wall.

Juan was recovering from his seventh surgery when I met him in an El Paso foster home. He spent his days watching TV, talking with his roommates about their home towns in Mexico, and rehabbing his leg, which was deep purple after several skin grafts. He eventually made it to New York to stay with an uncle. To avoid unwanted scrutiny from the government while his case wended through immigration court, he asked to use only his first name. Two years after the fall, his leg had barely improved. Standing for more than a few minutes at a time was painful, which made it impossible to hold down a job. He probably needed corrective surgery, though, without the finances to pay for one, the chances seemed unlikely. His life had for ever changed.

“I don’t live as I did before, I don’t do the same things, I’m adapting, trying to move forward,” he told me. But he was also haunted by what his life in the US might have been without injury. “Sometimes I can’t sleep, thinking about what would have happened to me if I hadn’t fallen.”

Going beyond medical care

Despite the growing body of evidence that border barriers are hazardous, there are few solutions to mitigate the damage they cause. Even if there were an integrated system to gather casualty data, the numbers do not reach the values and emotions of voters or elected officials, where decisions are made. People need a humanizing story, and to that end, Elmore began writing in June 2023 about his experiences in the emergency room and on the border. “It may be naive, but I believe if I can get the average American into that room with me to see the cost of our policies, I think I can change their mind,” he said.

In a piece for the Atlantic published in the summer of 2023, he tells the story of a mother and daughter who, after crossing the border, were struck by a car on the highway. The daughter was killed, and the mother’s body was broken. “We were going to Virginia,” she tells him as he prepares to leave the room. “Can my daughter be buried there?” In another story published a year later for the Texas Observer, he described the experience of walking into the emergency department after a mass tragedy. “All the rooms in the trauma zone were full. Nurses with blood-splattered gloves were racing to triage patients as Border Patrol agents and police officers lingered outside of rooms.” He gave readers a doctor’s view of the human cost of border policies; during an event at the University of Virginia, a student even approached him, eager to discuss his Atlantic article.

For Texas’s governor, Greg Abbott, the lesson of these harrowing stories is that even harsher enforcement measures are necessary. He launched Operation Lone Star in 2021, which, in addition to the estimated $11bn spent, has at times outdone the federal government in its cruelty. By late 2024, the governor turned his attention to healthcare providers, ordering state-funded hospitals to report their spending on migrants. Once Trump was back in the White House, doctors found they barely had time to stabilize their patients with fractured legs before border agents whisked them away with external fixators. Some doctors objected, and the practice soon ended, but the tactics scared off routine visits and silenced doctors who, fearing retribution, would advocate for them.

As a state institution, the medical staff at the University Medical Center in El Paso must be careful not to antagonize the governor over his border crackdown, a doctor not authorized to speak about hospital policy told me on condition of anonymity. The arrangement puts physicians in an ethical quandary.

“What should surgeons be doing in the case of an individual who is going to get the usual standard of care, where there is an imperative on the part of the government to deport that individual regardless of their health status?” the doctor said. The opportunity for reasonable coordination has melted away. That didn’t stop Elmore from questioning, somewhat sardonically, if the governor had deputized healthcare workers. The comment, published in local media, did not go over well with the governor’s office. Elmore received a talking to afterwards. His superiors at the hospital instructed him to be careful what he said to the media, and, for that matter, wrote.

Elmore was already under a lot of pressure and stress. He worked evening shifts at the hospital, caught a few hours of sleep, then started the morning at the Juárez clinic. He was also listening to a lot of Willie Nelson, especially on the drive to Mexico. Nelson’s warm, nasally twang poured through the stereo in Living in the Promiseland. With its pro-immigration lyrics – “Give us your tired and weak / And we will make them strong” – it became the unofficial soundtrack of Elmore’s time there.

But the work was taking an emotional toll. “It was disheartening to see the same patients come into the emergency department every day, with the same traumatic injuries – like a perverse Groundhog Day,” he said. By early 2024, pressure was mounting on friends who were being investigated by the state, and his patients were increasingly reporting injuries sustained from assaults by US and Mexican security forces. In the emergency department, he maintained a degree of emotional separation just to get the job done. “Then I spent all that time in Juárez talking to these patients and learning their stories, why they felt compelled to leave their home country, everything they experienced on their journey.”

Over the summer, I drove around El Paso with Elmore. We passed the spot where Spanish conquistador Don Juan de Oñate crossed the Rio Grande, which was occupied by US military infrastructure, and on to Sierra de Cristo Rey, where he hiked and ran for exercise in a place not far from where migrants were dying in the desert. Migrant advocacy groups had been documenting the trend, marking each death with a dot on the map. The image came to Elmore’s mind while surrounded by cheering fans at a minor league baseball game. “I thought about the senselessness of their deaths.”

Midway through 2025, migrant crossings had fallen to their lowest point in decades, and with so few arriving, severe injuries dropped to almost nothing. But there was still work to be done, particularly in Juárez, where Elmore had been mentoring medical students. He hoped they would be encouraged from the experience to think creatively about political pathologies, and, if necessary, go beyond direct medical care. “I’m hoping they advocate for their patients and bear witness on their behalf,” he said.

On his last shift in the emergency room, Elmore attended to a border wall patient from southern Mexico. He had treated more than 100 patients injured in falls from the border wall. This one, his last, had been deported earlier in the year, disrupting access to his diabetes medication. In Mexico, the patient was kidnapped, managed to escape, and then ended up in the hospital. He had a fractured ankle, though not the more severe pilon fracture in which the tibia, or shinbone, and sometimes the calf bone, or fibula, break through the skin. He was placed in a seat collar as a precaution against a cervical spinal injury. Elmore felt down his back, checking for deformities, but other than his broken ankle, the patient was not in pain. He ordered X-rays and CT scans to check for heel bone and lumbar spine fractures, common in wall fall injuries. The scans came back negative. An orthopedic team took over from there, stabilizing and splinting his ankle. The prognosis was good; the chances he would get humanitarian parole were far less optimistic. Despite his hardships, he would probably be deported. If that happened, he might return to Juárez. It is, after all, a city of migrants.

Some toil in Juárez’s factories, known as maquiladoras, or scrape by on whatever work they can find on the streets. Others make plans to cross the border. Their most pressing health need these days is learning to cope with the psychological trauma of a journey that brought them to the doorstep of a country that has in effect blocked them from asylum.

One of Elmore’s last midsummer evenings, before leaving for a fellowship in Virginia, a northbound train stopped a block from the International Bridge of the Americas so that Mexican immigration agents could search for people hitching a ride across the border. The boxcars were covered in graffiti, and the Union Pacific logo on the side with the slogan, “We build America,” written underneath.

A giant orange sun hung low on the horizon when the train began to move again, crossing the Rio Grande into the promised land.

This story was completed with the support of a fellowship from Columbia University’s Ira A Lipman center for journalism and civil and human rights and the USC Annenberg center for health journalism’s 2024 national fellowship