TPS and Diabetes: The Health Crisis Within the Immigration Crisis

Rose Carmelle Augustin used to check her blood sugar twice a day without thinking twice about it. The 58-year-old home health aide had been managing her type 2 diabetes for nearly a decade, relying on a combination of metformin, careful meal planning, and the employer-sponsored health insurance she received through the agency where she worked. That insurance covered her doctor visits, her lab work, her medications. It was part of the package that came with having legal work authorization, having a job, having a life built on the foundation of Temporary Protected Status. On July 28, 2026, the day after TPS protections expired for Haiti, Augustin checked her blood sugar at 6:00 a.m. and found it at 287, well above the safe range. She had not taken her medication for three days. She could not afford to refill the prescription without insurance. Augustin is not alone. Across Little Haiti, across Flatbush, across Mattapan and North Miami and every American community where Haitian TPS holders have built their lives, the termination of protected status has triggered a public health crisis that cuts far deeper than lost jobs and broken families. For the estimated 158,000 Haitian TPS holders in Florida alone, the loss of work authorization means the loss of employer-sponsored health insurance, which means the loss of access to the medications that keep chronic conditions like diabetes and hypertension under control. The clinic waiting rooms are filling up with patients whose A1C levels have spiked, whose blood pressure readings have climbed into dangerous territory, whose bodies are beginning to fail in the same month their legal status disappeared (FWD.us). The Disproportionate Burden of Diabetes in Haitian America Diabetes has always struck the Haitian community with particular ferocity. The International Diabetes Federation's 2025 Haiti Country Report placed the nation's diabetes prevalence at 8.5 percent among adults, affecting an estimated 541,800 people. The IDF projects that number will grow to 884,200 by 2050, a 63 percent increase driven by aging populations, dietary changes, and limited healthcare infrastructure. In a country where the healthcare system collapsed further after the 2010 earthquake and never fully recovered, diabetes management has always been a battle fought with limited resources (IDF Diabetes Atlas). But the diabetes crisis among Haitian immigrants in the United States is shaped by a different set of factors, factors that the termination of TPS has now intensified to a breaking point. Research published in the journal BMC Public Health has documented that Haitian immigrants face distinct genetic and physiological risk factors for type 2 diabetes. Studies show that Haitians have a distinct variance in hemoglobin concentration, which can affect the accuracy of standard diabetes diagnostic tests and may put individuals at risk for T2D at a lower threshold than current clinical recommendations account for. The standard hemoglobin A1C test, which measures average blood glucose over three months, may underestimate or overestimate glycemic control in individuals of African descent depending on hemoglobin variants, leading to misdiagnosis or inadequate treatment (PMC7513641). Compounding these biological factors are the social determinants of health that disproportionately affect immigrant communities. The CDC National Diabetes Statistics Report, released in 2026, confirmed that Black non-Hispanic adults are 24 percent more likely to have diabetes than white adults and face a 78 percent higher death rate from the disease. Haitian immigrants, as a subset of the Black American population, experience these disparities acutely, often amplified by language barriers, immigration-related stress, and limited access to culturally competent healthcare (CDC). The undiagnosed rate among Haitian diabetics compounds the tragedy. The IDF Haiti Country Report estimates that 29.4 percent of Haitian adults with diabetes are undiagnosed, meaning they are living with a condition that is silently damaging their organs, their blood vessels, their vision, and their kidneys without any intervention. For TPS holders who lose their insurance, the undiagnosed rate will almost certainly climb as routine screenings become unaffordable and preventive care becomes a luxury they can no longer afford (IDF Diabetes Atlas). 8.5% Diabetes prevalence among Haitian adults (2024) 541,800 Haitian adults living with diabetes 884,200 Projected number of Haitian diabetics by 2050 29.4% of Haitian diabetics who are undiagnosed 24% Higher likelihood of diabetes for Black adults vs. white adults 78% Higher diabetes death rate for Black adults The Day the Insurance Stopped The mechanism by which TPS termination becomes a medical crisis is brutally simple. Employment authorization documents (EADs) for Haitian TPS holders expired on July 24, 2026, three days before the formal termination of the designation itself. Once those documents expired, employers were required to terminate the employment of TPS holders or face sanctions under immigration law. With termination came the loss of employer-sponsored health insurance, which for most Haitian TPS holders was the only health coverage they had (Miami Herald). KFF, the independent health policy research organization formerly known as the Kaiser Family Foundation, published an analysis in May 2026 that modeled the health impacts of TPS termination across affected nationalities. The KFF report found that TPS holders are significantly more likely to be uninsured than the general U.S. population, in part because many work in industries like hospitality, home health care, construction, and agriculture that are less likely to offer employer-sponsored coverage. Even among those who do have job-based insurance, the loss of work authorization creates an immediate coverage gap that is nearly impossible to bridge (KFF). Rose Carmelle Augustin's experience illustrates the gap. Her employer, a home health care agency in North Miami, offered health insurance to all employees with valid work authorization. When her EAD expired, the agency had no choice but to place her on unpaid leave. Her insurance ended the same day. She applied for Medicaid but was told that her immigration status made her ineligible for most public benefits. She looked into the Affordable Care Act marketplace but found that plans without subsidies were unaffordable on her reduced income. She began rationing her metformin, taking half the prescribed dose to make the bottle last longer. By the third day, her blood sugar had climbed from a controlled 130 to a dangerous 287 (Miami Herald). Her story is being repeated thousands of times across South Florida. Dr. Nasiruddin Nazarally, the medical director of the UHI Community Care Clinic in Opa-locka, reported that his clinic saw a 40 percent increase in new patients during the last week of July 2026. Many of them were Haitian TPS holders who had lost their insurance and were seeking care for the first time in months or years. "We are seeing patients whose diabetes is completely out of control because they stopped taking their medications when they lost their insurance," Nazarally told the Miami Herald. "Some of them have not seen a doctor in over a year. They come in with A1C levels above 10, blood pressure readings that are stroke-level, and no way to afford the medications we prescribe" (Miami Herald). The Cortisol Crisis: How Deportation Fear Raises Blood Sugar The termination of TPS does not only affect diabetes management indirectly, through the loss of insurance and access to care. There is a direct biological pathway by which the stress of immigration enforcement makes diabetes harder to control. That pathway runs through cortisol, the primary stress hormone, and its powerful effects on glucose metabolism. Ohio State University Wexner Medical Center published a research review in 2020 documenting the link between cortisol and blood sugar. Cortisol, which the body releases in response to stress, triggers the liver to produce more glucose while simultaneously making cells less sensitive to insulin. This is an evolutionary adaptation: in a short-term crisis, the body floods the bloodstream with energy to fuel a fight-or-flight response. But when stress becomes chronic, as it does for immigrants living under the constant threat of deportation, the elevated cortisol persists, and blood sugar remains chronically high (Ohio State Wexner Medical Center). The research on immigration enforcement and cortisol is stark. A 2018 study published in the Journal of Immigrant and Minority Health examined household fear of deportation in relation to chronic stressors and found that individuals living in mixed-status households, where some members are undocumented or hold precarious legal status, reported significantly higher levels of perceived stress and demonstrated flatter diurnal cortisol curves. A flattened cortisol curve, where the normal morning peak and evening trough are blunted, is associated with poor glucose control, increased insulin resistance, and higher risk of diabetes complications (PMC12399042). For Haitian TPS holders, the cortisol crisis has been building for years. The first attempt to terminate Haitian TPS came in 2017, during President Trump's initial term, and was blocked by litigation until the Supreme Court's June 2025 ruling in Mullin v. Doe cleared the way for termination. For nearly a decade, TPS holders have lived with the knowledge that their protected status could be revoked at any time. Each new court ruling, each new executive order, each new news cycle has triggered a fresh surge of stress hormones. The Supreme Court's decision on June 25, 2026, which held that federal law bars judicial review of executive branch decisions to terminate TPS, represented the culmination of that stress. The diurnal cortisol curves flattened further. The blood sugar climbed higher. A 2022 study published in PMC examined barriers to type 2 diabetes management among older adult Haitian immigrants in the United States and found that immigration-related stress was one of the most frequently cited obstacles to effective diabetes self-care. Participants described how fear of deportation made it difficult to attend medical appointments, maintain regular medication schedules, and adhere to dietary recommendations. One participant explained that she avoided going to the doctor because she was afraid of being stopped by immigration enforcement on the way. Another described how the stress of her legal situation made her crave sugary foods, which she knew was bad for her diabetes but could not control (PMC7513641). The study's authors concluded that diabetes management interventions for Haitian immigrants must address immigration-related stress as a core component of treatment. But with TPS terminated, the stress has not been alleviated. It has been multiplied. And the healthcare system, already strained, has no mechanism for prescribing legal security. The Caregivers Who Cannot Get Care Perhaps the most painful dimension of the TPS diabetes crisis is the paradox at its center: the very people who provide healthcare to millions of Americans are among those losing access to care themselves. The numbers are staggering. More than 112,000 Haitians work in the U.S. healthcare system, according to an analysis published by Documented New York on June 30, 2026. An estimated 35,000 Haitian TPS holders work in Florida's healthcare sector alone, serving as nursing assistants, home health aides, patient care technicians, and medical assistants. Nationwide, approximately 13,000 nursing assistants are Haitian TPS holders (Documented NY). These are the workers who staff the nursing homes, the assisted living facilities, the home health agencies, and the hospitals that care for America's aging population. They bathe and feed and monitor the vital signs of elderly patients, many of whom are white, many of whom are U.S. citizens, many of whom would have no one to care for them without the labor of immigrant workers. They spent the COVID-19 pandemic on the front lines, exposing themselves to the virus day after day while the nation clapped for essential workers and then returned to normal life. Now their legal status has been revoked, their work authorization has expired, and they cannot afford the insulin they need to survive (Documented NY). The Documented NY analysis, published just days after the Supreme Court ruling, described the impending crisis in New York's healthcare system. Nearly 33,000 Haitian TPS holders call New York home, and a significant portion work in healthcare. Mount Sinai Health System, one of New York's largest hospital networks, reported in early 2026 that approximately 1,900 of its employees were TPS holders, the majority from Haiti. NYU Langone Health reported roughly 650 TPS holders among its staff. Montefiore Medical Center in the Bronx, which serves a large Haitian community, employs hundreds more. When those workers lose their authorization, the hospitals lose not just their labor but also their patients, because the Haitian community that relied on those healthcare workers for culturally competent care will lose access to providers who speak Creole and understand their needs (Documented NY). In Florida, the crisis is even more acute. The Miami Herald reported on July 29, 2026, that the loss of Haitian TPS workers in healthcare would create a double crisis: a shortage of essential healthcare workers at the same time that a surge of newly uninsured TPS holders floods the community health clinic system. South Florida's nursing homes, which rely heavily on Haitian certified nursing assistants, face immediate staffing shortages. The home health agencies that allow elderly Floridians to age in place are losing their workforce. And the clinics that serve as the safety net for the uninsured are being overwhelmed by demand (Miami Herald). Shabbir Motorwala, a founding board member of the UHI Community Care Clinic in Opa-locka, described the paradox in plain terms. "Our clinic staff includes Haitian nurses, Haitian medical assistants, Haitian community health workers," Motorwala said. "They are the ones providing care to the community. And now they themselves are losing their insurance. They themselves cannot afford their medications. They are showing up at our clinic as patients, and we are trying to help them while knowing that we might lose them as colleagues" (Miami Herald). The Clinic That Refuses to Turn Anyone Away The UHI Community Care Clinic in Opa-locka, a working-class city in Miami-Dade County, has become a symbol of both the crisis and the community's response to it. Founded in 2006 by a coalition of community leaders who recognized the chronic shortage of healthcare access in one of the poorest communities in South Florida, the clinic has served as a medical home for thousands of uninsured and underinsured patients, including a large Haitian TPS holder population. In the last year alone, the clinic saw more than 6,000 patients, many of them managing diabetes, hypertension, and other chronic conditions with limited resources (Miami Herald). The clinic's approach to diabetes care is holistic, recognizing that managing blood sugar requires more than prescribing medication. UHI started a community garden where patients can grow fresh vegetables, addressing the food insecurity that makes diabetes management nearly impossible for low-income families. The clinic operates a mobile grocery bus that brings fresh produce directly to the neighborhoods where patients live, bypassing the food deserts that otherwise force residents to rely on convenience stores and fast food. The clinic offers free eye exams and prescription glasses, recognizing that diabetic retinopathy is a leading cause of preventable blindness among patients with uncontrolled diabetes. It provides dental care, understanding that periodontal disease both exacerbates and is exacerbated by diabetes (Miami Herald). In the weeks since the Supreme Court ruling, the clinic has seen a surge in patients who have lost their insurance and are seeking care for the first time. Dr. Nazarally described schedules that are completely full, with staff working overtime to accommodate the influx. The clinic has expanded its telehealth services, in part because some patients have expressed fear of traveling to appointments, worried about encountering immigration enforcement on the way. "We have patients who request telehealth specifically because they are afraid to come in person," Nazarally told the Miami Herald. "They are worried that if they leave their homes, they will be detained. The stress of that fear is making their diabetes worse, and we cannot prescribe a solution for that" (Miami Herald). The clinic's telehealth program was developed during the COVID-19 pandemic, when the same fears of leaving home kept patients away. Now it has become an essential tool for patients who are hiding in plain sight, afraid that any trip outside could be their last as a free person in the United States. The clinic offers same-day medication delivery for patients who cannot come to pick up their prescriptions, and it has expanded its pharmacy hours to accommodate patients who are working multiple jobs to save money before they lose their income entirely (Miami Herald). The Food Insecurity Crisis Within the Diabetes Crisis Diabetes management requires not just medication but also consistent access to healthy food. For TPS holders who have lost their jobs, or who are working reduced hours because their employers cannot legally employ them, food insecurity has become an acute crisis. The UHI clinic's community garden and mobile grocery bus represent innovative responses to this problem, but they cannot meet the scale of the need. Food insecurity is directly linked to poor diabetes outcomes. Patients who cannot afford to buy fresh vegetables, lean protein, and whole grains are forced to rely on inexpensive, calorie-dense, nutrient-poor foods that cause blood sugar to spike. The stress of food insecurity itself elevates cortisol, further destabilizing glucose control. And the loss of income that comes with TPS termination is pushing families who were already struggling into outright food deprivation. "We have patients who are choosing between buying insulin and buying food," Shabbir Motorwala said. "That is a choice no one should have to make. We are trying to address the food side through our garden and our grocery bus, but if they cannot afford the insulin, the food alone will not keep them alive. And if they cannot afford the food, the insulin alone will not keep them healthy. They need both, and right now they cannot afford either" (Miami Herald). The Hypertension Connection Diabetes rarely travels alone. For most Haitian TPS holders managing diabetes, hypertension is a comorbid condition that requires its own set of medications, its own monitoring regimen, its own access to care. The loss of insurance means not just the loss of metformin and insulin but also the loss of ACE inhibitors, beta blockers, diuretics, and the other medications that keep blood pressure in check. Untreated hypertension accelerates the damage that diabetes does to the body. It increases the risk of heart attack, stroke, kidney disease, and diabetic retinopathy. For patients with both conditions, the loss of medication access is not merely inconvenient; it is life-threatening. The combination of uncontrolled diabetes and uncontrolled hypertension is a recipe for catastrophic health events that will land patients in emergency rooms, at far greater cost to the healthcare system than the preventive care they have been denied. The CDC National Diabetes Statistics Report, released in early 2026, documented that 89 percent of adults with diagnosed diabetes also have hypertension. Among Black adults with diabetes, the rate of hypertension is even higher. For Haitian TPS holders who have lost access to care, the dual burden of diabetes and hypertension represents a medical emergency that is unfolding slowly, patient by patient, as their medication supplies run out and their bodies begin to fail (CDC). 112,000+ Haitians working in the U.S. healthcare system 35,000 Haitian TPS holders in Florida healthcare 13,000 Nursing assistants nationwide who are Haitian TPS holders 158,000 Haitian TPS holders in Florida 89% of diabetic adults also have hypertension The Mental Health Toll The physical health crisis of TPS termination is inseparable from the mental health crisis that accompanies it. Depression and anxiety are common among people with diabetes, and the rates are even higher among those who face the additional stressors of immigration precarity, financial insecurity, and social isolation. The termination of TPS has triggered a wave of depression, anxiety, and post-traumatic stress among Haitian community members that in turn makes diabetes management even more difficult. Ammcise Apply, a public health researcher at Binghamton University, published an analysis in The Conversation on June 26, 2026, examining the disproportionate impact of TPS termination on Haitian women's mental and physical health. Apply's research documented that Haitian women in Florida bear the highest levels of migration-related stress, in part because they carry the dual burden of providing for their families while navigating the immigration system on behalf of their households. The stress manifests in poor sleep, unhealthy eating patterns, and difficulty adhering to medication regimens, all of which directly worsen diabetes outcomes (Apply). "For many of these women, the loss of TPS is not just a legal change. It is a health crisis," Apply wrote. "The chronic stress of living in fear of deportation has measurable physiological effects. It elevates cortisol. It raises blood pressure. It destabilizes blood sugar. And it makes it nearly impossible to engage in the kind of consistent self-care that diabetes management requires" (Apply). The Conversation piece cited interviews with Haitian women in Little Haiti who described the psychological toll of the TPS termination as more debilitating than any physical symptom. One woman, a 45-year-old home health aide with type 2 diabetes, told Apply that she had stopped checking her blood sugar because seeing the high numbers only made her more anxious. Another described lying awake at night trying to calculate how long her medication supply would last, knowing that she could not afford to refill her prescriptions once they ran out. A third said she had stopped eating because she could not afford both food and insulin, and she chose the insulin because without it she would die immediately, whereas without food she would die slowly (Apply). The mental health infrastructure that could address these issues is itself inadequate. Culturally competent mental health services, especially those offered in Creole, are scarce even in communities with large Haitian populations. The clinics that provide primary care for diabetes are doing their best to screen for depression and anxiety, but they lack the resources to provide ongoing mental health treatment. Patients who need therapy, psychiatric medication, or substance use treatment for the coping mechanisms they have developed are largely left to manage on their own. The State of the Safety Net The community health centers that serve as the safety net for uninsured patients are facing a surge that they were not designed to handle. Borinquen Health Care Center, which operates multiple locations in Miami-Dade County, has long been a primary care home for the Haitian community. Camillus Health Concern provides medical and dental care to the homeless and uninsured in Miami. Community Health of South Florida, known as CHI, operates a network of clinics that serve low-income patients across the southern part of the county. All of them are reporting increased demand from Haitian TPS holders who have lost their insurance (Borinquen Health Care Center). The KFF analysis published in May 2026 warned explicitly that TPS termination would overwhelm the community health center system. The report estimated that the loss of TPS for all affected nationalities would push more than 100,000 patients into the already strained safety net, with Haitian TPS holders representing the largest share. Community health centers, which operate on thin margins and rely on federal funding that is itself under threat, have limited capacity to absorb new patients, especially patients with complex chronic conditions that require ongoing specialist care (KFF). The nation's network of community health centers has been celebrated as a model for delivering high-quality primary care to underserved populations. They provide services on a sliding fee scale based on income, meaning that even uninsured patients can receive care at reduced cost. They offer case management, health education, and translation services that help bridge the gaps that low-income patients face. But the model assumes a certain volume of patients and a certain level of funding. When the patient volume suddenly spikes and the funding remains flat, the system breaks (KFF). In Opa-locka, Dr. Nazarally described the impossible math facing his clinic. "We are seeing more patients than ever before, but we cannot increase our revenue because our patients cannot pay," he said. "We rely on grants and donations to cover the gap, but those funds are not unlimited. We are going to have to make difficult decisions about how many patients we can serve, and those decisions will mean that some people will not get the care they need" (Miami Herald). The Children of TPS Diabetics The health crisis of TPS termination extends beyond the TPS holders themselves to their families, including the estimated 50,000 U.S. citizen children who depend on Haitian TPS parents' income. When a parent with diabetes loses access to medication and becomes incapacitated by a stroke, a heart attack, or a diabetic coma, the entire family is affected. When a parent dies from a preventable complication of uncontrolled diabetes, the children are left without a caregiver. The multi-generational impact of TPS termination on health outcomes has not been systematically studied, but the anecdotal evidence is accumulating. Children are missing school because their parents cannot drive them, having lost their licenses along with their work authorization. Families are moving in with relatives because they can no longer afford rent, disrupting the stability that children need to thrive. And children are witnessing their parents' health deteriorate in real time, a trauma that will have lasting effects on their own mental and physical health. The clinics that serve TPS families are seeing increasing numbers of children with stress-related symptoms: headaches, stomachaches, anxiety, depression. The pediatricians at UHI and Borinquen report that children are asking questions their parents cannot answer: Are we going to have to leave? Is Mama going to die because she cannot get her medicine? The health crisis, like the immigration crisis, does not respect generational boundaries. Haiti's Own Diabetes Crisis For TPS holders who are considering returning to Haiti rather than living in the United States without legal status, the diabetes crisis they would face in their home country is itself a deterrent. Haiti's healthcare system, which was fragile before the 2010 earthquake and was devastated by it, is in no position to absorb hundreds of thousands of returning diabetics who have become accustomed to American standards of care. The IDF Diabetes Atlas documents that Haiti has one of the lowest densities of healthcare providers in the Western Hemisphere, with approximately 0.25 physicians per 1,000 population, compared to 2.6 per 1,000 in the United States. Insulin, metformin, and other essential diabetes medications are frequently in short supply, and when they are available, they are prohibitively expensive for most Haitians. The public hospital system, Minustah, and the network of NGO-run clinics cannot meet the existing demand for diabetes care, let alone a surge of returnees (IDF Diabetes Atlas). For TPS holders with diabetes, the choice is stark. Stay in the United States without legal status, without insurance, without access to medications, and hope that the safety net clinics can keep them alive. Or return to Haiti, where the medications they need may not exist and the healthcare system that could prescribe them is functionally absent. Either way, the prognosis is poor. The Policy Failure as Public Health Emergency Public health officials across the country have begun to describe the TPS termination as a public health emergency, though the federal government has not declared one. The Miami-Dade County Health Department issued a statement on July 27, 2026, expressing deep concern about the health impacts of the termination and urging affected residents to seek care at community health centers. But the county has limited authority to address the root causes of the crisis: the loss of insurance, the loss of income, the loss of legal status that is driving patients away from care (Miami Herald). The KFF analysis recommended several policy responses that could mitigate the health impacts of TPS termination: extending Medicaid eligibility to TPS holders regardless of their immigration status, providing emergency bridge funding to community health centers, and allowing TPS holders to purchase health insurance through the Affordable Care Act marketplace regardless of their employment status. None of these recommendations have been implemented (KFF). Congress has not acted on Senate Bill 4814, which would require the Department of Homeland Security to redesignate Haiti for TPS through January 2029. The bill, introduced by a bipartisan coalition of senators from states with large Haitian populations, has languished in committee since its introduction in early 2026. Without legislative action, the executive branch has no mechanism to reinstate TPS, and the Supreme Court has ruled that the courts have no authority to review the termination decision (FWD.us). The result is a policy vacuum in which the health of tens of thousands of people is deteriorating without any institutional mechanism to stop it. The clinics are doing what they can, but they cannot prescribe legal status. They cannot restore work authorization. They cannot reverse the Supreme Court decision that set this crisis in motion. They can only treat the symptoms of a policy failure that is making people sick and, in some cases, killing them. What Insulin Costs Without Insurance The financial arithmetic of diabetes without insurance illustrates the impossibility of the situation facing TPS holders. A monthly supply of insulin, depending on the type and dosage, can cost between $300 and $1,000 without insurance. A month's supply of metformin, one of the most commonly prescribed diabetes medications, costs roughly $30 to $60 without insurance. Blood glucose test strips, which patients with diabetes need to use multiple times daily, cost approximately $0.50 to $1.00 each, adding another $60 to $120 per month. Doctor visits, which should occur at least every three months for patients with diabetes, cost $100 to $300 per visit without insurance. Laboratory tests, including the A1C test that measures average blood glucose over three months, cost $50 to $100 each. A comprehensive diabetes management regimen that was manageable with employer-sponsored insurance becomes a several-thousand-dollar monthly expense without it. For a TPS holder who has lost their job and is trying to survive on savings or the income of family members, those numbers are impossible. The result is what clinicians call non-adherence, a clinical term that obscures the real phenomenon: people are dying because they cannot afford to stay alive. It is not that they do not understand the importance of taking their medication. It is that they cannot pay for it. The Day the Clinic Broke On July 29, 2026, the same day the Miami Herald published its report on the health impacts of TPS termination, UHI Community Care Clinic in Opa-locka reached its breaking point. The clinic's schedule was completely full by 7:00 a.m., and the waiting room was overflowing with patients who had arrived without appointments, hoping to be squeezed in. Dr. Nazarally saw patients through lunch and into the evening, treating diabetic ulcers, prescribing emergency medication refills, and referring patients with dangerously high blood pressure to the emergency room. By the end of the day, the clinic had seen 50 percent more patients than it was designed to handle. Shabbir Motorwala, the founding board member, described the scene as overwhelming but not surprising. "We knew this was coming. We have been preparing for it for months. But there is no way to prepare for the human reality of it, the faces of people who are scared and sick and have nowhere else to go. We are going to keep the doors open as long as we can. But we cannot do this alone. We need help. We need the government to recognize that this is a public health emergency, because it is. People are going to die" (Miami Herald). The clinic's community garden, planted earlier in the year to address food insecurity among diabetic patients, had become a source of fresh vegetables for dozens of families. The mobile grocery bus, which delivered produce to neighborhoods that lacked access to fresh food, was running six days a week instead of three. The free eye exam program had a waiting list of more than 200 patients, many of them diabetics who needed retinal screenings to check for diabetic retinopathy. The dental clinic, which treats the gum disease that both causes and is worsened by diabetes, was also at capacity (Miami Herald). Every part of the clinic's operation was stretched to its limit. And still the patients kept coming. The Long-Term Prognosis The health effects of TPS termination will not be fully measured for years. The patients who lose access to insulin today will develop complications tomorrow: diabetic retinopathy that leads to blindness, diabetic nephropathy that leads to kidney failure, diabetic neuropathy that leads to amputations. The hypertension that goes untreated will lead to strokes and heart attacks. The stress that elevates cortisol will continue to destabilize blood sugar, creating a vicious cycle in which the very fear of deportation makes the body less able to survive its effects. Community health clinics across the country are bracing for the wave of complications that will arrive in the months and years ahead. They are expanding their capacity where they can, applying for emergency grants, and training community health workers to provide diabetes education in Creole. But they are operating against headwinds that no amount of local effort can overcome. The policy decision that created this crisis was made at the highest level of the federal government, and it cannot be reversed by a clinic in Opa-locka, no matter how hard its staff works. For Rose Carmelle Augustin, the 58-year-old home health aide who could not refill her metformin after losing her insurance, the immediate future is uncertain. She has an appointment at UHI next week, a late addition to Dr. Nazarally's overbooked schedule. She will get a free sample of metformin from the clinic's pharmacy, enough to last a few weeks. She will be connected with a community health worker who speaks Creole and can help her apply for the clinic's sliding fee program. She will be told to come back in three months for a follow-up A1C test, assuming the clinic can fit her into the schedule by then. But the underlying problem will not be solved by a sample of metformin and a follow-up appointment. Augustin needs a job with health insurance to manage her diabetes long term, and she cannot get a job without work authorization. She needs work authorization to get her TPS back, and she cannot get TPS back because the Supreme Court has ruled that the government is allowed to terminate it. She is caught in a trap that no clinical intervention can escape. "I took care of other people's grandparents for fifteen years," Augustin told the Miami Herald. "I helped them with their medications. I made sure they took their insulin. I called the doctor when their blood pressure was too high. And now I cannot take care of myself. I cannot afford my own medication. Who is going to take care of me?" (Miami Herald). The Community Garden as Resistance In the shadow of the crisis, the UHI Community Care Clinic's community garden has become an unlikely symbol of resistance. The garden, which grows okra, collard greens, callaloo, and other vegetables familiar to Haitian cuisine, was designed to address the food insecurity that makes diabetes management so difficult for low-income patients. But it has taken on a deeper meaning in the weeks since the TPS termination. Patients who cannot afford to buy fresh vegetables at the supermarket can come to the garden and harvest what they need, free of charge. The garden is staffed by volunteers from the community, many of them TPS holders who find meaning in growing food for their neighbors even as their own legal status dissolves. The mobile grocery bus carries the garden's produce into neighborhoods where grocery stores are scarce, bringing fresh food directly to the people who need it most. "The garden is about more than vegetables," Shabbir Motorwala said. "It is about dignity. It is about saying that we will not let our community starve, that we will not let our neighbors die from diseases that are preventable and treatable. The government may have taken away their status, but it cannot take away our commitment to each other. That is what this garden represents. It is our declaration that we will take care of our own" (Miami Herald). The Undiagnosed Majority The 29.4 percent of Haitian diabetics who are undiagnosed represent a ticking time bomb within the TPS crisis. These are people who have diabetes but do not know it, who are not monitoring their blood sugar, who are not taking medication, who are not making dietary changes, because they have never been told that their bodies are failing. For TPS holders who have lost their insurance, the diagnosis may never come. The routine blood work that would catch elevated glucose is a luxury they can no longer afford. The preventive visit where a doctor would notice the warning signs is a memory of a time when they had access to care. The undiagnosed diabetics will become the complications of tomorrow. They will show up in emergency rooms with diabetic ketoacidosis, a life-threatening condition that requires intensive hospital treatment. They will develop infections in their feet that will not heal, leading to partial or complete amputations. They will lose their vision to diabetic retinopathy that could have been prevented with early intervention. They will require kidney dialysis for diabetic nephropathy, a treatment that costs the healthcare system tens of thousands of dollars per patient per year. The cost of untreated diabetes far exceeds the cost of treating it early. But the early treatment requires an infrastructure of access that the TPS termination has destroyed. The Final Irony The final irony of the TPS diabetes crisis is that the very people who are losing access to diabetes care are the ones who have been providing diabetes care to others. The nursing assistants who checked blood sugar, administered insulin, and monitored diabetic patients in nursing homes cannot afford their own blood sugar test strips. The home health aides who prepared diabetic meals for their clients cannot afford the healthy food they need for themselves. The medical assistants who took patients' blood pressure readings cannot afford to see a doctor when their own hypertension spikes. It is a cruel inversion of the healthcare relationship, a system in which the caregivers become the patients and then are told that there is no room for them in the system they helped to sustain. The 13,000 nursing assistants nationwide who are Haitian TPS holders have devoted their working lives to the care of others. Now they are being abandoned by the society they served. "I have been a nursing assistant for twelve years," said Marie, a 39-year-old TPS holder from Port-au-Prince who works at a nursing home in Miami. "I have taken care of hundreds of patients. I have held their hands when they were scared. I have called their families when they were dying. And now I am the one who is scared. I am the one who needs someone to hold my hand. But there is no one" (Miami Herald). The Path Forward There is no easy path forward for the Haitian TPS holders whose diabetes has been destabilized by the termination of their protected status. The community health clinics that are their last resort are operating at capacity and beyond, sustained only by the dedication of their staff and the urgency of the need. The legislative solutions that could address the crisis, from TPS redesignation to expanded Medicaid access to emergency health funding, remain stalled in a Congress that has shown little appetite for immigration-related legislation. In the meantime, the clinics continue to do what they can. UHI Community Care Clinic is expanding its telehealth services, hiring additional Creole-speaking staff, and applying for every grant it can find. Borinquen Health Care Center is extending its hours and recruiting volunteer physicians. Community Health of South Florida is opening satellite clinics in neighborhoods with large Haitian populations. The safety net is being stretched to its breaking point, but it has not broken yet. For the patients themselves, the path forward is a matter of survival. They are rationing their medications, skipping meals to afford insulin, and praying that their bodies will hold out until the political winds shift. They are relying on each other, sharing what little they have, and finding strength in the community that has sustained them through every crisis since the earthquake that brought them to this country sixteen years ago. The health crisis within the immigration crisis is not a temporary disruption. It is a permanent catastrophe for thousands of people whose bodies are paying the price for a policy decision made in Washington. The question is not whether the clinics can keep up, or whether the medications will run out, or whether the blood sugar levels will spike. The question is what kind of society allows its caregivers to die because they cannot afford the insulin that would keep them alive. The answer, for now, is this one. "I took care of other people's grandparents for fifteen years. And now I cannot take care of myself." Rose Carmelle Augustin, Haitian TPS holder and former home health aide Works Cited Apply, Ammcise. 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