From a perch on the border fence, thirty feet above an isolated stretch of desert near El Paso, the early-morning air chilled Juan in his rain-soaked clothes. In the pitch dark, he couldn’t see far along the row of towering steel bollards that compose this section of the barrier, though he knew they extended for miles on either side of him.

He and his aunt had flown from Mexico City to Ciudad Juárez just a few hours earlier. If everything went according to plan, they would get to New York City in three or four days. But Juan hadn’t anticipated the immensity of the fence, nor did he have time to reconsider the wisdom of this climb. He had been third in a line of about twenty migrants who were taking turns ascending a store-bought metal ladder. Each who went up had a rope tied around his waist. Their smuggler, remaining on the ground on the Mexican side, held the other end. Once they reached the top, the smuggler would slowly release the rope to lower them down to American soil.

But for reasons Juan can’t explain—other than, possibly, the compromising effects of the adrenaline coursing through his veins—he untied the smuggler’s rope and cast it aside. Instead, he grabbed onto another rope he saw hanging down from one of the bollards. It wasn’t until he began his descent that he realized his mistake: this other rope was barely a meter long. He might have climbed back up, or even tried to shimmy down one of the rusty-hued bollards. Instead, he panicked, let go of the rope, and leaped to the ground, about 25 feet down. “I didn’t think about if I would hurt myself,” Juan told me later. “The only thing I thought about was how I was going to land.”

As it happened, he landed on his feet, but immediately collapsed and cried out in pain. He knew that something was broken. His left leg was bent gruesomely in the wrong direction, and he felt the warmth of blood soaking his pants. It was 3 a.m., and Juan lay helplessly in the muck.

Having witnessed the fall, the remaining migrants aborted their crossing. Only his aunt and the smuggler stayed behind, comforting him from the south side of the fence until help got there. Through the narrow gaps between the bollards, they passed him water, along with cigarettes to help keep himself from passing out. Despite their calling for help, an emergency medical responder didn’t arrive until 10 a.m. “Imagine seven hours, lying on the ground and in pain,” he said. “I thought no one was coming for me and that I was going to die there.”

Had he remained there much longer that morning in May, he might have died—not an unusual fate among migrants attempting to cross the border—or he might have lost his leg. But as is the case with most patients who suffer severe injuries in the area, Juan was rushed to University Medical Center, the only level 1 trauma center within 250 miles of El Paso, and one of just three near the Texas-Mexico border. There he learned he had shattered his tibia at the ankle, an injury known in medical parlance as a pilon fracture.

It is the most common injury suffered by the thousands of migrants who have fallen from the sections of fence or levee wall that former president Trump’s administration built, including along 133 miles of the desert around El Paso. These new segments extend thirty feet high in many areas, twelve feet taller than the eighteen-foot fence they replaced. The migrants falling from these significantly greater heights are suffering a constellation of dire injuries, among them blunt cerebrovascular trauma that can lead to severe strokes, pelvic trauma, permanent paralysis, stillbirths, and even death.

Almost as soon as construction got underway on the taller fence, University Medical Center began seeing an uptick in these injuries. Since 2019, the trauma center has treated about 1,100 patients who fell from the top, or near the top, of the barrier. (The two other level 1 trauma centers located on the Texas border, both in the Rio Grande Valley, did not respond to requests for their data on injuries associated with the border wall.) The U.S. Border Patrol would not provide to Texas Monthly the total number of wall injuries it has tracked in recent years, or comment on how much those figures have changed since the taller fence was built. But the agency reported nineteen fatalities due to falls during the twelve months leading up to October 2021, according its most recent publicly released data.

About three-quarters of the patients taken to University Medical Center are landing awkwardly on their feet, the force of which transfers through their lower body and spine. “It’s a three-story jump,” said Alan Tyroch, the trauma medical director at UMC and a surgery professor at the Texas Tech University Health Science Center in El Paso. “It’s Newton’s law—the higher you fall, the more acceleration you have. And more kinetic energy is being impacted on your body.” At a height of eighteen feet, someone plummeting reaches a speed of 23 miles per hour upon impact. At thirty feet, the speed is 30 miles per hour. Put another way, a body crashes into the ground from the taller fence with 130 percent greater impact force.

The sheer volume of leg fractures, which comprise the majority of border wall-related injuries, has made UMC’s four orthopedic trauma specialists experts in treating pilon fractures, which are otherwise relatively rare. “I’ve done more of these fractures in the last three years than most trauma surgeons would ever do in their career,” said Adam Adler, an orthopedic surgeon at UMC and one of Juan’s doctors. In addition to pilon fractures, the hospital sees a variety of orthopedic injuries, especially to the lower extremities, including broken heel bones. “My residents graduate with more experience doing these procedures than a significant number of the trauma-trained, fellowship-trained surgeons just because we see a lot more of them than anyone else does.”

Hospitals elsewhere along the U.S.-Mexico border have seen the number of patients sustaining injuries from falls at the border wall increase dramatically in recent years. In April 2022, University of California San Diego Health, also a level 1 trauma center, published the first of several studies on the rise of these injuries since 2019. The researchers confirmed that this spike coincided with the increased height of the barrier.

Jay Doucet, chief of the trauma division at UC San Diego and one of the authors of the study, said that with each new section of border wall—dating back to the late nineties—there was a corresponding bump in migrant injuries. These included sections built during the Bush and Obama administrations. But with the thirty-foot-tall sections under Trump, traumatic injuries surged to a much greater degree than the earlier upticks—almost 460 percent between 2019 and 2021 compared to the prior three-year period.

In another study, UC San Diego neurosurgeon Alexander Tenorio found that since 2019 there had been a record number of spinal injuries suffered at the section of the border wall nearest San Diego. “Now we’re seeing multiple-level fractures that require surgery, and patients who stay in the hospital and intensive care unit for longer periods,” Tenorio told me, adding that traumatic brain injuries have similarly increased.

“I’ve been pushing this evidence that it’s all due to the thirty-foot barriers because all data shows that once you get above twelve to thirteen feet of height, you start seeing these more severe injuries to the brain,” Tenorio said. This summer he testified about the physical toll of the heightened border wall during a congressional subcommittee hearing. “As a physician, of course, I can’t speak to what their intentions were for thirty-foot barriers,” he said. “The main thing now is what could we do about it to halt further height extensions.”

Doctors from trauma centers on the U.S.-Mexico border, including centers in the Rio Grande Valley and El Paso, created the Border Region Doing Research on Trauma Consortium in 2021 to better understand immigration enforcement–related injuries. The group’s first study, published in August, described the increase in traumatic injuries along the border as having reached humanitarian-crisis levels. For Tenorio, the issue is also personal. “My parents migrated from Mexico from that same border,” he said. “I see these patients and think, this could be my cousin, my uncle, my aunt.”

Finding allies in Congress, where migration is among the most politically divisive issues, has not come easy. While the consortium takes no official stance on government action regarding the border wall, it hopes to elucidate the magnitude of the problem from a health care standpoint and to shed light on the impact that physical trauma has on migrants and their families, as well as the U.S. health care system. “Everyone has their political opinions. . . . The reality is the patients are here, and we have to take care of them,” Adler said. “If a patient comes in, and they have an open, limb-threatening pilon fracture, which is common, you can’t just be like, ‘sorry, you fell off the border wall, goodbye.’ ”

When a patient injured at the border fence is brought to University Medical Center—about one per day since the start of 2021—the trauma specialist on call will administer emergency care. Since many of the injured migrants are abandoned by their smugglers, they are usually found alone, after their falls. Their skin may be covered in blisters from the desert heat by the time they arrive at the hospital. If the injury is to the lower leg, the crushing effect from the fall has likely compacted their limb, which will have to be restored to its original length. The patient is fitted with an external fixator, a device that stabilizes fractures and realigns the bone using pins, wires, and rods. After that, the migrant is discharged to wait two to four weeks for surgery while the swelling subsides, giving their tissue and skin a chance to recover.

“Unfortunately for us, we don’t get to see a lot of them back after surgery, which is problematic,” Adler said. Ideally, his patients would return to see him several times in the year after a surgery to address any complications, but he estimates that no more than 15 percent of his patients injured in falls from the border wall return for follow-up care. Considering that most have no health insurance—a few states offer undocumented immigrants state-funded coverage—it is reasonable to assume that many do not receive continued care. “Historically the quality of life for these types of injuries is poor, so if they aren’t receiving post-operative care, it’s obviously detrimental,” Adler said.

For as long as a migrant remains in Border Patrol custody, the agency picks up the tab for their medical expenses. But more often than not, migrant patients are released from the agency’s custody soon after arriving at an emergency room, which leaves the hospital to eat the cost. At UC San Diego, the median cost per spinal-injury patient has spiked 70 percent since the arrival of the thirty-foot wall, due to patients suffering multiple and more-severe injuries that require more treatment. Meanwhile, University Medical Center racked up $20 million in migrant medical fees between 2021 and 2022, spending about $36,000 per patient who fell off the wall. To cover what the government does not, the El Paso hospital draws from its $180 million charity care budget, half of which is funded by El Paso County taxpayers.

Some of the injured migrants end up at the Annunciation House in downtown El Paso. In the 45 years since he cofounded the shelter, Ruben Garcia has never had so many dropped off at his door. In addition to those with broken legs, he said, “We’ve seen a number of people with the tailbone fractured. We’ve seen people with broken ribs, broken arms. We’ve seen fractured spines. We’ve seen fractured skulls.” The shelter took in about fifty injured migrants during the first half of 2023, and when I visited, in mid-July, two men were nursing pilon fractures in the men’s dormitory ahead of their surgeries. One of them, Otto, a migrant from Guatemala City, sat on his bunk bed in the darkened room, and explained how, on an early morning in late June, he fell.

Otto had not anticipated having to climb the fence using a rope ladder or having to wrap his arms around one of the steel bollards at the top, which was hot from baking in the sun, to slide down it to the ground. “I burned myself,” he said. “And I slipped.” Otto fractured his ankle in the fall. The bone broke through the skin, and he bled profusely. “It came out like it was squirting from a syringe.” Left alone by the smuggler, he used his belt as a tourniquet and called 911, which arrived an hour later. When I met him, he was set to have surgery in a couple of weeks, after which he planned to meet friends in Oklahoma and find work as a gardener. Like most migrants released from Border Patrol custody, Otto said he will comply with the legal requirements the government has imposed on him and show up to immigration court. “A person has the need to migrate,” he said. “But if the [immigration] judge tells me I have to leave the country, I have to go.”

Patients who require greater assistance are sent to adult foster homes elsewhere in El Paso. In one of these, four men, including Juan, were in the living room watching the news in Spanish when I stopped by in July. The manager of the home said he had another four migrants in a second house he managed. They come to him often with broken arms and legs, and spinal injuries—and less frequently, head injuries and paralysis. “A lot of them are scared. They don’t know where they are going, and I have to explain what is happening to them,” said the manager, who asked to remain unnamed because he had been harshly criticized in the past for providing care and housing to unauthorized migrants. Juan’s injury was more complicated to deal with than most, requiring multiple surgeries performed by different surgeons. “We had to make sure he followed up with each,” the manager told me.

It took seven operations to put Juan’s broken leg back together, before the tendons and nerves could be allowed to begin to heal. Doctors had to remove the skin from his right foot to repair the soft tissue on his injured ankle. The result left purple scars on both legs. He required physical therapy twice weekly to massage and bend his leg, along with lifting weights to strengthen his arms for the walker he would have to use in the months ahead.

His family in New York sent him money, and in August he joined them there. Most migrant patients cannot pay their exorbitant medical bills. Juan was fortunate to receive free care at a hospital in New York, where he is going to therapy twice a week. He can’t afford to pay for his hospital stay or surgery in El Paso, and anything the Department of Homeland Security doesn’t cover, the hospital will be stuck with.

Juan figures it could be months before his leg is well enough for him to return to work. A court date scheduled for August was indefinitely postponed after his move to New York, but one way or another an immigration judge will decide whether he can remain in the country. If he is allowed to stay, he will look for work in a restaurant, though standing for hours on end could prove difficult. “I came here thinking about my future because I want to get ahead,” Juan said. “I didn’t come with that mentality that something might happen to me along the way. I never imagined this.”