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Book Review: Threshold

When I was asked to review Threshold, a book whose subtitle is Emergency Responders on the U.S.-Mexico Border, I said sure. I was mostly curious about author Ieva Jusionyte—a paramedic who happens to be a Harvard anthropology professor—but I also welcomed the chance to read about atypical EMS.

I was right about the atypical part. EMS? Not so much.

Threshold is a passionate, persuasive work—a conscientious exposé of interdiction practices along the Arizona-Sonora line—but it’s no more about EMS than One Flew Over the Cuckoo’s Nest is about nursing. That’s a potential dissatisfier for those of you seeking yet another cathartic account of life and death on the streets. Potential dissatisfier #2 is that Threshold confronts us with controversial views on one of the decade’s most polarizing topics: immigration. If you crave a “big, beautiful wall” and feel rage when you read opinions to the contrary, please don’t buy this book; rage is bad for the digestion.

Here are just a few provocative quotes about border management from Jusionyte:

  • “Rather than being ‘accidents’…emergencies on the border are deliberately caused by government policies.”
  • “When do (emergency responders) start recognizing border infrastructure as a weapon? What is the threshold of politics in emergency response?”
  • “The people who ordered (the current) wall to be built have come to wield laws as weapons in hopes of protecting the illusion of the national economy and social order.”

Jusionyte is diligent about supporting those observations with evidence. That doesn’t mean you’ll agree with her. Nuanced aspects of oft-debated issues once hinted at common ground between opposing beliefs, but such paths toward civility have been largely overrun by weaponized social media. You may need to pause, check your blood pressure, then ask yourself if it’s worth reading an unpopular point of view when there’s only a messenger to blame.

Threshold is best suited for readers who want an anthropologist’s take on trauma and illness along the border. Yes, there are first-person accounts of patient care, but they are secondary to the author’s underlying thesis about “the politics of wounding and rescue”—that the location and design of border infrastructure not only discourages illegal crossings but summarily punishes the noncompliant with disability or death. That backstory is as unfamiliar to most prehospital providers as EMS in outer space.

Some of Jusionyte’s most compelling prose details man-made obstacles to border encroachment. Jagged rocks piled at the base of 12-foot walls virtually ensure jumpers will suffer angulated ankle fractures or worse. And those who try to shorten that drop by lowering themselves from the corrugated steel’s serrated edges often leave amputated fingers behind. An analogy would be roads built with hairpin curves solely to punish speeders.

Weather and terrain are equally dangerous to migrants whose routes into the U.S. are necessarily circuitous. When daytime temperatures routinely exceed 100ºF and scant water supplies are polluted by chemicals or bacteria, the environment becomes an ally to law enforcement. Getting into the U.S. is often easier than staying alive long enough to enjoy any perceived benefits.

How should EMS providers regard tactics such as heatstroke and mangled limbs to slow illegal immigration? Does the end justify the means? Those are fundamental questions posed by Threshold. It isn’t a fun read. Jusionyte writes more about controlling people than rescuing them, but by the time you realize there’s not much medicine in Threshold, you’ve already learned more about one of the most divisive issues of our time than you ever will on Facebook.

Mike Rubin is a paramedic in Nashville and a member of EMS World’s editorial advisory board. Contact him at

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