RALEIGH, N.C. -- COVID-19 cases have spiked among the state's Latinx community, yet most of these residents can't access basic health services.
Advocates say the pandemic has highlighted how the country's public health system has neglected undocumented residents. While Hispanics make up around 9% of North Carolina's population, as of mid-June, they accounted for 44% of the state's COVID-19 cases, according to state data. Many of the state's immigrants work in food processing, construction, deliveries or cleaning services and can't afford to stay home if they feel sick.
Juvencio Rocha-Peralta, executive director of the Association of Mexicans in North Carolina, said this population faces unique barriers.
"These communities that we're talking about, they're undocumented individuals, they don't qualify for any public services," he said. "So what we did was provide some emergency funding for rent, electric and other needs that they need at home."
Since March, Rocha-Peralta's organization has been leading a COVID-19 task force made up of health providers, community partners and community members that meet weekly to identify how they can support the Latinx community during the pandemic. He said foundations such as the Kate B. Reynolds Charitable Trust and others have provided cash to help residents pay for doctor visits, medical bills and prescription medications.
Rocha-Peralta said many Latinx residents are wary of getting tested for COVID-19 due to fear of deportation. Worsening matters is the Trump administration's public-charge rule, which went into effect early this year. He said local public-health departments could play a critical role in gaining the trust of the undocumented community.
"Health departments and other public agencies, they need to establish some advisory councils and advisory boards to advise those institutions about this population," he said. "Communities-based organizations place a significant role working with marginalized communities."
The emergency aid has been a temporary solution, but Rocha-Peralta noted that the crisis has highlighted the need for a new approach to public health in marginalized communities. One report found North Carolina ranks 40th in the nation in spending on public health, and in 2019, North Carolina was one of only eight states where public health funding decreased.
"We've been working in this community for 19 years," he said, "but when the pandemic hit us, there was a reason to change things around and also, not to react, but to come up with a plan to address the needs of these communities."
He also pointed to the need for mental health resources in the immigrant community. Many families have experienced high levels of stress related to poverty and trauma, worsened during the pandemic.
North Carolina public health funding data is online at tfah.org.
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By Chantal Flores for Yes! Media.
Broadcast version by Freda Ross for Texas News Service reporting for the Yes! Media-Public News Service Collaboration
If Indi Tisoy has a single dream, it is to reach the United States. Her desire is so strong, in fact, that she waits at the border because it makes her feel closer to that dream. Tisoy, who is a member of the Inga Indigenous community, left the Colombian Amazon's Putumayo department with her family when she was 12 to seek better economic opportunities in the city of Bucaramanga.
When Tisoy was 20, she began transitioning. Within five years of her transition, Bucaramanga, which was once her refuge, no longer felt safe. So in late 2024, Tisoy, who is now 25, decided to begin journeying toward the United States because she's drawn to what she calls the country's "open-minded culture."
"The last time I went [to my community] was very difficult because there was criticism, insults, threats, and I made the decision to leave Colombia," Tisoy said from a migrant shelter in northern Mexico. "I said I'm [also] not doing well in Bucaramanga, so I want to change my life."
Since taking office, U.S. President Donald Trump has taken a series of executive actions targeting migrants as well as transgender and nonbinary people. For trans migrants like Tisoy, who are already undertaking arduous journeys to the United States, asylum options have been shut down, and the hope of finding safe haven is dwindling.
In response to the changing environment, key initiatives in Mexico are focusing on developing more long-term and comprehensive support for LGBTQ migrants, who may be in Mexico for a longer time than originally intended.
A Continuous Search for Safety
The LGBTQ community experiences continuous displacement, especially if they are rejected by their communities and families and are seeking access to medical care. However, there is little data on LGBTQ refugees and asylum seekers in the U.S., which hinders a better understanding of their characteristics and experiences.
A study by the Williams Institute at UCLA School of Law found that between 2012 and 2017 an estimated 11,400 asylum applications were filed by LGBTQ individuals. Nearly 4,000 of these applicants sought asylum specifically due to fear of persecution based on their sexual orientation or gender identity.
Raúl Caporal, director of Casa Frida, which provides refuge for LGBTQ migrants in Mexico City, Tapachula, and Monterrey, Mexico, explained that the majority of the individuals they serve are fleeing violence and seeking international protection.
"The population we focus on leaves their countries because of persecution and violence motivated by sexual orientation, gender identity, and expression," Caporal says.
"[This is compounded] by organized crime taking advantage of their vulnerability, the absence of the state, and the inability to access justice institutions when they try to report crimes."
Latin America and the Caribbean report the highest number of trans murders of any region in the world. According to Transrespect Versus Transphobia Worldwide, 70% of trans murders globally occur there, with the majority of victims being Black trans women, trans women of color, and trans sex workers. In Mexico alone, according to data from Mexico's National Trans and Nonbinary Assembly (Asamblea Nacional Trans No Binarie), more than 55 trans people were killed last year, making it the second deadliest country in the world for trans people, after Brazil.
Brigitte Baltazar, a Mexican trans activist who resides in Tijuana, Mexico, after being deported from the U.S. in 2021, explains that trans asylum seekers no longer see the U.S. as a safe haven as Donald Trump signs harsh executive orders targeting trans and nonbinary people as well as immigrants. Baltazar says that these executive orders "increase the stigma and discrimination [trans migrants are] already experiencing," which "creates a state of panic."
Though Casa Frida documented that 67% of the people they served in 2024 didn't have the U.S. as their final destination, the remaining 33% intended to reach the U.S. using CBP One, a mobile app that migrants can use to apply to enter the U.S. However, that option was discontinued by the Trump administration in January.
Activists and organizations agree that strengthening access to asylum in Mexico, along with health care and job opportunities, is key to sustaining support for trans migrants.
"Mexico has a great opportunity to strengthen its local public policies on integration, particularly at the municipal and state levels," Caporal adds. "Ultimately, it is the municipalities where refugees will reside, where they will find work close to their homes, where they will generate an income, and where people can continue their studies."
Strengthening Support Systems for Trans Migrants in Mexico
The persecution and violence LGBTQ individuals face often continue during their journey. Shortly after crossing the Mexico-Guatemala border, Tisoy and a fellow group of migrants were kidnapped. She recalled being held in the backyard of a house for 12 days until her best friend in the United States could raise $1,000 to meet a ransom demand.
Caporal explained that the lack of state protection and inaccessible justice institutions increases the vulnerability of trans migrants, making them easy targets for organized crime. In its latest report, Amnesty International highlights the risks and precariousness faced by people in the U.S.-Mexico border, at the hands of both state and non-state actors. The report warns that many migrants are forced to pay bribes to Mexican authorities, criminal groups, or individuals at checkpoints.
Tisoy arrived in Matamoros, Tamaulipas-a city less than three miles away from Brownsville, Texas-days before Trump's inauguration. She planned to cross the river and request asylum, but she didn't have the $200 fee she needed to pay the cartel to cross. With deportations beginning, she now waits near the border as she doesn't want to risk being taken back to Colombia.
"In this journey, you have to be very positive because if you get depressed, you're in a city that isn't yours, in a country that isn't your own," Tisoy says. "I cried and prayed a lot, but then I realized I had to keep going. I wiped away my tears and here I am."
Waiting near the U.S.-Mexico border is increasingly dangerous. Most migrants in Matamoros remain in shelters due to threats of being kidnapped and robbed. For Tisoy, even being at the shelter can be uncomfortable due to the lack of specific support for LGBTQ individuals.
After families complained about her presence in a shelter with children, she moved to a neutral room in a nearby shelter, but her stay is uncertain with more migrants seeking an extended stay in Mexico. "I arrived normally, and no one had said anything to me," Tisoy explained. "Then one mother said I was trans and went to complain, but I didn't understand why she did it."
After the cancellation of CBP appointments, some migrants returned to Casa Frida to seek legal advice for requesting asylum in Mexico. To seek asylum in Mexico, individuals must apply within 30 days of arrival at a Commission for Refugee Aid (COMAR) office. The application requires completing a form explaining their reasons for leaving their home country, providing supporting documentation, and detailing their fear of persecution based on factors such as race, religion, nationality, political opinion, gender, or social group membership.
Casa Frida, along with other organizations, is currently working with COMAR to find alternatives to the 30-day rule for those who didn't apply for asylum because they were waiting for their CBP appointment. Caporal says that Mexico must strengthen its asylum system and provide COMAR with the resources to meet the increasing demand for guidance, incorporating both gender and sexual diversity perspectives.
"We are preparing a draft bill to reform the refugee law in the Chamber of Deputies, which seeks to include persecution based on sexual orientation and gender identity as a direct cause for obtaining and recognizing refugee status," he added.
Guaranteeing Safe and Dignified Spaces
Along with legal counseling, Baltazar said "dignified access to health care" is also a critical need. Baltazar, who also coordinates the LGBTQ program at the migrant organization Al Otro Lado, explained that Mexico's bureaucratic and often inhumane health system poses a significant challenge, particularly for trans individuals.
She regularly accompanies trans migrants to health centers to access antiretrovirals or STI medications, a challenge even for internally displaced Mexicans. The lack of documentation-common for both domestic and foreign migrants who fled without documents or lost them on their journey-further complicates their access to proper health care.
"With hormone treatments, unfortunately there is no program and there are no specialized doctors, like endocrinologists, who can care for this population," Baltazar added. "This puts their health at risk since they do not have a hormone treatment controlled by a specialist."
Tisoy has been struggling to get tested after being sexually assaulted on the train north. "I spent 15 days on the train, and I was raped. So it's important to me to get tested," she says. During a stop at Casa Frida in Mexico City, she tried to get tested, but after three days, she decided to continue her journey rather than waiting.
Before Trump's inauguration, there was a focus on helping people "while they were able to cross," but now, Baltazar says there's an urgent need for a longer-term strategy where people can access health care and other services and opportunities in Mexico.
"People cannot return to their countries or regions because their lives are in danger. The idea is to offer them workshops and integration support, giving vulnerable people tools so they can do anything in a new country," Baltazar added. "Perhaps they even discover passions they didn't have the opportunity to explore in their countries because they weren't free or didn't have access to schools, universities, or job training."
Most shelters and resources for LGBTQ asylum seekers rely on grassroots efforts by activists like Baltazar and organizations like Casa Frida, which depend on volunteer and community support. Casa Frida obtained external funding to continue growing, but nearly 60% of its 2025-2026 budget is at risk due to USAID cuts.
Though they are developing an emergency plan to continue operations, Caporal warned that wait times for services will likely increase. "Our operational capacity will likely be reduced," Caporal says. "This may result in longer wait times for those who visit our facilities daily and we will have to ensure that we continue providing the 54,000 meals we serve daily."
Caporal agrees that the focus should be on strengthening paths to settle in Mexico and pushing to implement these integration policies, particularly at the local level. Casa Frida is concentrating on these local integration opportunities, providing a safer environment where individuals can explore a wide range of life options.
"That is when they begin to make the decision that in reality it is not that they want to reach the United States," Caporal added. "In reality what they want is to reach a safe territory where they can live in freedom, autonomy, and-above all-with pride in being who they are."
Chantal Flores wrote this article for Yes! Media.
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By Arielle Zionts for KFF Health News.
Broadcast version by Zamone Perez for Virginia News Connection reporting for the KFF Health News-Public News Service Collaboration
A growing number of states have made it easier for doctors who trained in other countries to get medical licenses, a shift supporters say could ease physician shortages in rural areas.
The changes involve residency programs — the supervised, hands-on training experience that doctors must complete after graduating medical school. Until recently, every state required physicians who completed a residency or similar training abroad to repeat the process in the U.S. before obtaining a full medical license.
Since 2023, at least nine states have dropped this requirement for some doctors with international training, according to the Federation of State Medical Boards. More than a dozen other states are considering similar legislation.
About 26% of doctors who practice in the U.S. were born elsewhere, according to the Migration Policy Institute. They need federal visas to live in the U.S., plus state licenses to practice medicine.
Proponents of the new laws say qualified doctors shouldn’t have to spend years completing a second residency training. Opponents worry about patient safety and doubt the licensing change will ease the doctor shortage.
Lawmakers in Republican- and Democratic-leaning states have approved the idea at a time when many other immigration-related programs are under attack. They include Florida, Iowa, Idaho, Illinois, Louisiana, Massachusetts, Tennessee, Virginia, and Wisconsin.
President Donald Trump has defended a federal visa program that many foreign doctors rely on, but they could still be hampered by his broad efforts to tighten immigration rules.
Supporters of the new licensing laws include Zalmai Afzali, an internal medicine doctor who finished medical school and a residency program in Afghanistan before fleeing the Taliban and coming to the U.S. in 2001.
He said most physicians trained elsewhere would be happy to work in rural or other underserved areas.
“I would go anywhere as long as they let me work,” said Afzali, who now treats patients who live in rural areas and small cities in northeastern Virginia. “I missed being a physician. I missed what I did.”
It took Afzali 12 years to obtain copies of his diploma and transcript, study for exams, and finish a three-year U.S.-based residency program before he could be fully licensed to practice as a doctor in his new country.
But a commission of national health organizations questions whether loosening residency requirements for foreign-trained doctors would ease the shortage. Doctors in these programs could still face licensing and employment barriers, it wrote in a report that makes recommendations without taking a stance on such legislation.
Erin Fraher, a health policy professor at the University of North Carolina who advises the commission and studies the issue, said lawmakers who support the changes predict they will boost the rural health workforce. But it’s unclear whether that will happen, she said, because the programs are just getting started.
“I think the potential is there, but we need to see how this pans out,” Fraher said.
Afzali struggled to support his family while trying to get his medical license. His jobs included working at a department store for $7.25 an hour and administering chemotherapy for $20 an hour. Afzali said nurse practitioners at the latter job had less training than him but earned nearly four times as much.
“I do not know how I did it,” he said. “I mean, you get really depressed.”
Many of the state bills to ease residency requirements have been based on model legislation from the Cicero Institute, a conservative think tank that sent representatives to testify to legislatures after proposing such programs in 2020.
The new pathways are open only to internationally trained physicians who meet certain conditions. Common requirements include working as a physician for several years after graduating from a medical school and residency program with similar rigor to those found in the U.S. They also must pass the standard three-part exam that all physicians take to become licensed in the U.S.
Those who qualify are granted a restricted license to practice, and most states require them to do so under supervision of another physician. They can receive full licensure after several years.
About 10 of the laws or bills also require the doctors to work for several years in a rural or underserved area.
But states without this requirement, such as Tennessee, may not see an impact in rural areas, researchers from Harvard Medical School and Rand Corp. argued in the New England Journal of Medicine. In addition to including that condition, states could offer incentives to rural hospitals that agree to hire doctors from the new training pathways, they wrote.
Lawmakers, physicians, and health organizations that oppose the changes say there are better ways to safely increase the number of rural doctors.
Barbara Parker is a registered nurse and former Republican lawmaker in Arizona, where the legislature is considering a bill for at least the fourth year in a row.
“It’s a really poor answer to the doctor shortage,” said Parker, who voted against the legislation last year.
Parker said making it easier for foreign-trained physicians to practice in the U.S. would unethically poach doctors from countries with greater health care needs. And she said she doubts that all international residencies are on par with those in the U.S. and worries that granting licenses to physicians who trained in them could lead to poor care for patients.
She is also concerned that hospitals are trying to save money by recruiting internationally trained doctors over those trained in the U.S. The former often will accept lower pay, Parker said.
“This is driven by corporate greed,” she said.
Parker said better ways to increase the number of rural doctors include raising pay, expanding loan repayment programs for those who practice in rural areas, and creating accelerated training for nurse practitioners and physician assistants who want to become doctors.
The advisory commission — recently formed by the Federation of State Medical Boards, the Accreditation Council for Graduate Medical Education, and Intealth, a nonprofit that evaluates international medical schools and their graduates — published its recommendations to help lawmakers and medical boards make sure these new pathways are safe and effective.
The commission and Fraher said state medical boards should collect data on the new rules, such as how many doctors participate, what their specialties are, and where they work once they gain their full licenses. The results could be compared with other methods of easing the rural doctor shortage, such as adding residency programs at rural hospitals.
“What is the benefit of this particular pathway relative to other levers that they have?” Fraher said.
The commission noted that while state medical boards can rely on an outside organization that evaluates the strength of foreign medical schools, there isn’t a similar rating for residency programs. Such an effort is expected to launch in mid-2025, the commission said.
The group also said states should require supervising physicians to evaluate participants before they’re granted a full license.
Afzali, the physician from Afghanistan, said some internationally trained primary care doctors have more training than their U.S. counterparts, because they had to practice procedures that are done only by specialists in the U.S.
But he agreed with the commission’s recommendation that states require doctors who did residencies abroad to have supervision while they hold a provisional license. That would help ensure patient safety while also helping the physicians adjust to cultural differences and learn the technical side of the U.S. health system, such as billing and electronic health records, the commission wrote.
Fraher noted that doctors in programs with supervision requirements need to find an experienced colleague with the time and interest in providing this oversight at a health facility willing to hire them.
The commission pointed out other potential hurdles, such as malpractice insurers possibly declining to cover physicians who obtain state licenses without completing a U.S. residency. The commission and the American Board of Medical Specialties also pointed to the issue of specialty certification, which is managed by national organizations that have their own residency requirements.
Physicians who aren’t eligible to take board exams could lose out on employment opportunities, and patients might have concerns about their qualifications, the board wrote. But it said a majority of its member boards would consider certifying these doctors if states added requirements it recommended.
Lawmakers’ plans to use these new licensing pathways to increase the number of rural doctors will require the foreign-trained doctors to navigate all these obstacles and unknowns, Fraher said.
“There’s a lot of things that need to happen to make this a reality,” she said.
Arielle Zionts wrote this story for KFF Health News.
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