After back-to-back, eight-hour shifts at a chiropractor's office and a rehab center, Nirva arrived outside an elderly woman's house just in time to help her up the front steps.
Nirva took the woman's arm as she hoisted herself up, one step at a time, taking breaks to ease the pain in her hip. At the top, they stopped for a hug.
"Hello, bella," Nirva said, using the word for "beautiful" in Italian. "Hi, baby," replied Isolina Dicenso, the 96-year-old woman she has helped take care of for seven years.
The women each bear accents from their homelands: Nirva, who asked that her full name be withheld, fled here from Haiti after the 2010 earthquake. Dicenso moved here from Italy in 1949. Over the years, Nirva, 46, has helped her live independently, giving her showers, changing her clothes, washing her windows, taking her to her favorite parks and discount grocery stores.
Now Dicenso and other people living with disabilities, serious illness and the frailty of old age are bracing to lose caregivers like Nirva due to changes in federal immigration policy.
Nirva is one of about 59,000 Haitians living in the United States under Temporary Protected Status (TPS), a humanitarian program that gave them permission to work and live here after the January 2010 earthquake devastated their country. Many work in healthcare, often in grueling, low-wage jobs as nursing assistants or home health aides.
Now these workers' days are numbered: The Trump administration decided to end TPS for Haitians, giving them until July 22, 2019, to leave the country or face deportation.
In California, about 55,000 immigrants are protected by TPS, the vast majority from El Salvador. They are expected to lose their protection in September 2019. In Southern California, home to a large Central American immigrant population, senior care businesses could lose employees because of the change in status of some Salvadoran workers, said Elayne Carver, president of the California Assn. of Senior Care Homes.
Carver, who owns a senior-care home in Orange County, said it is already difficult to find the right workers to care for seniors. The hours can be long — including 12-hour shifts — and the pay is usually minimum wage. Despite the low pay, the job of caring for others requires seasoned employees "with experience under their belt," Carver said. Foreign-born workers often fit that bill, she said. In California, Carver added, caregivers tend to be Latino or Filipino.
Nationwide, 1 million immigrants work in direct care — as certified nursing assistants, personal care attendants or home health aides — according to the Paraprofessional Healthcare Institute, a New York-based organization that studies the workforce. Immigrants make up one in four workers, said Robert Espinoza, PHI's vice president of policy.
Turnover is high, he said, because the work is difficult and wages are low. The median wage for personal care attendants and home health aides is $10.66 per hour, and $12.78 per hour for CNAs. Workers often receive little training and leave when they find higher-paying jobs at retail counters or fast-food restaurants, he said.
The country faces a severe shortage in home health aides. With 10,000 baby boomers turning 65 each day, an even more serious shortfall lies ahead, according to Paul Osterman, a professor at Massachusetts Institute of Technology's Sloan School of Management. He predicts a national shortfall of 151,000 direct-care workers by 2030, a gap that will grow to 355,000 by 2040. That shortage will escalate if immigrant workers lose work permits, or if other industries raise wages and lure away direct-care workers, he said.
Nursing homes in Massachusetts are already losing immigrant workers who have left the country in fear, in response to the White House's public remarks and immigration proposals, said Tara Gregorio, president of the Massachusetts Senior Care Assn., which represents 400 elder care facilities. Nationally, thousands of Haitians have fled the United States for Canada, some risking their lives trekking across the border through desolate prairies, after learning that TPS would likely end.
Employers are fighting to hold on to their staff: Late last year, 32 Massachusetts healthcare providers and advocacy groups wrote to the Department of Homeland Security urging the acting secretary to extend TPS, protecting the state's 4,724 Haitians with that special status.
"What people don't seem to understand is that people from other countries really are the backbone of long-term care," said Sister Jacquelyn McCarthy, CEO of Bethany Health Care Center in Framingham, Mass., which runs a nursing home with 170 patients. She has eight Haitian and Salvadoran workers with TPS, mostly certified nursing assistants. They show up reliably for 4:30 a.m. shifts and never call out sick, she said. Many of them have worked there for over five years. She said she already has six CNA vacancies and can't afford to lose more.
"There aren't people to replace them if they should all be deported," McCarthy said.
Nirva works 70 hours a week taking care of elderly, sick and disabled patients. She started working as a CNA shortly after she arrived in Boston in March 2010 with her two sons.
She chose this work because of her harrowing experience in the earthquake, which destroyed her home and killed hundreds of thousands, including her cousin and nephew. After the disaster, she walked 15 miles with her sister, a nurse, to a Red Cross medical station to try to help survivors. When she got there, she recounted, the guards wouldn't let her in because she wasn't a nurse. Nirva spent an entire day waiting for her sister in the hot sun, without food or water, unable to help. It was "very frustrating," she said.
"So, when I came here — I feel, people's life is very important," she said. "I have to be in the medical field, just to be able to help people."
The work of a CNA or home health aide — which includes dressing and changing patients and lifting them out of bed — was difficult, she found.
"At the beginning, it was very tough for me," Nirva said, especially "when I have to clean their incontinence. … Some of them, they have dementia, they are fighting. They insult you. You have to be very compassionate to do this job."
A few months ago, Nirva was injured while tending to a 285-pound patient who was lying on her side. Nirva said she was holding the patient up with one hand while she washed her with the other hand. The patient fell back on her, twisting Nirva's wrist.
Injury rates for nursing assistants were more than triple the national average in 2016, federal labor statistics show. Common causes were falling, overexertion while lifting or lowering, and enduring violent attacks.
It's not clear how many direct-care workers rely on TPS, but PHI calculates there are 34,600 who are non-U.S. citizens from Haiti, El Salvador, Nicaragua, for which TPS is also ending next year, and Honduras, whose TPS designation expires this July. In addition, another 11,000 come from countries affected by Trump's travel ban, primarily from Somalia and Iran, and about 69,800 are non-U.S. citizens from Mexico, PHI's Espinoza said.
Even immigrants with secure legal status may be affected when family members are deported, he noted. Under Trump, non-criminal immigration arrests have doubled.
The "totality of the anti-immigrant climate" threatens the stability of the workforce — and "the ability of older people and people with disabilities to access home healthcare," Espinoza said.
Asked about the impact on the U.S. labor force, a DHS official said that "economic considerations are not legally permissible in TPS decisions." By law, TPS designation hinges instead on whether the foreign country faces adverse conditions, such as war or environmental disaster, that make it unsafe for nationals to return to, the official said.
The biggest hit to the immigrant workforce that cares for older patients may come from another program — family reunification, said Robyn Stone, senior vice president of research at LeadingAge, an association of nonprofit groups that care for the elderly. Trump is seeking to scrap the program, which he calls "chain" migration, in favor of a "merit-based" policy.
Osterman, the MIT professor, said the sum of all of these immigration policy changes may have a serious impact. If demand for workers exceeds supply, he said, insurers may have to restrict the number of hours of care that people receive, and wages may rise, driving up costs.
"People aren't going to be able to have quality care," he said. "They're not going to be able to stay at home."
But since three-quarters of the nation's direct-care workers are U.S. citizens, then "these are clearly not 'jobs that Americans won't do,'" argued David Ray, spokesman for the Federation for American Immigration Reform, which supports more restrictive immigration policies.
The United States has 6.7 million unemployed people, he noted. If the healthcare industry can't find anyone to replace workers who lose deportation protections granted under TPS and the Deferred Action for Childhood Arrivals programs, he said, "then it needs to take a hard look at its recruiting practices and compensation packages. There are clearly plenty of workers here in the U.S. already who are ready and willing to do the work."
Angelina Di Pietro, Dicenso's daughter and primary caretaker, disagreed. "There's not a lot of people in this country who would take care of the elderly," she said. "Taking care of the elderly is a hard job."
"Nirva, pray to God they let you stay," said Dicenso, sitting back in her living room armchair after a long walk and ravioli lunch. "What would I do without you?"