The constitutional right to abortion access has become the key issue as eyes across the nation have turned toward the confirmation of Judge Brett Kavanaugh, and discussion swirls over what would happen if Roe v. Wade were struck down if he is appointed to the Supreme Court. But for the women living in the southern tip of Texas, the realities of living in a post-Roe world have been normal for quite some time.

In the Rio Grande Valley, there is just one abortion clinic — a Whole Woman’s Health clinic in McAllen, Texas. The walls of the facility are painted purple, with quotes by notable women emblazoned on them. It’s outfitted with exam rooms and medical equipment. The experience of going to the McAllen facility is like going to any other Whole Woman’s Health clinic. Except where it’s not.

Outside the front door is a security guard, and the road taking you to the clinic is flanked by anti-choice billboards. Surrounding the clinic are throngs of protesters. And aside from confronting these obstacles, girls and women seeking abortion care also have to confront the state laws further restricting their access.

“There are already so many barriers in Texas — 24-hour waiting periods, the mandatory script we have to read, physician-only laws that mean that the state restricts care so that only physicians can provide abortions…” Dr. Bhavik Kumar, a fellow of Physicians for Reproductive Health and the Medical Director of Whole Woman’s Health, said in an interview.

“On paper, these all seem like not the worst things and you could maybe understand why the state would enforce these laws and think they’re not a big deal. But there are barriers in place for folks who already make it into the clinic and these only add to that. It’s difficult to pay for this care, so they either end up waiting weeks for care while they find the money or they wait too long and you can’t get it anymore.”

This is what abortion could look like if Kavanaugh is confirmed — a world where abortion services might still exist in some places, but become too impossible to access for many, with distance, expense, logistics, and other factors compounded in the ways unique to already-marginalized communities.

Brett Kavanaugh answers a question during a third round of questioning on the third day of his Senate Judiciary Committee confirmation hearing, Thursday, Sept. 6, 2018. Jacquelyn Martin/AP

In a post-Roe world, abortion wouldn’t likely be illegal everywhere in the U.S., but just in those states that seek to ban the procedure. The Center for Reproductive Rights has identified 22 states that are at a high level of risk for banning abortion through a variety of legislative mechanisms should Roe fall; these states come together to comprise a large swath of the south and middle of the U.S., leaving realistic, reasonable abortion access left to the two coasts.

Laws that women in Texas are already dealing with also make abortion seem dangerous to a woman’s health and wellbeing. And as the Supreme Court stands to potentially overturn the federal guarantee of safe, legal abortion, that feeling of endangerment because of the choices that politicians, and not doctors, make about medicine, stands to impact even more girls and women.

“Unfortunately, politicians make these restrictions and then clinicians in Texas become the face of these laws,” Kumar said. “I have to be the face of someone saying, ‘Sorry I can’t do that.’ I have to tell someone yes this is medically safe, and if we were in New York or California, I could do this and these things would be an options. It’s confusing for patients. They ask, ‘Why can’t I do that?’ and ‘Does the state know something you’re not telling me?’”

“As a physician, after years of training, I have the skills and knowledge to take care of people, but my hands are being tied.”

The Rio Grande Valley already often feels like its own state, separate from the rest of Texas. It’s the region that has the highest concentration of unincorporated communities in the United States — unofficial towns called colonias that run along the 340-mile stretch of U.S.-Mexico border that are self-organized, but lacking in general resources like garbage pick-up and street lights and electricity. It’s a medically underserved region where transportation is a huge barrier, and the lack of access to health providers and services means that people simply can’t get to the care they need, which isn’t anywhere close to where they are. Already, residents in the Rio Grande frequently cross the border to get things like birth control pills, since that form of preventative health care is basically already wholly inaccessible to them where they are.

Though, there are plenty of fake women’s health clinics — often referred to by anti-choice advocates as crisis pregnancy centers. Here, misinformation is regularly given, pushing access to actual medical care even further out of reach for those who need it most.

“The idea of having abortion states and non-abortion states is basically what we already have in Texas,” Kumar said. “We have certain metropolitan cities where [abortion] is available and then rural areas like the Rio Grande Valley where it’s not accessible. There are no clinics west of I-35 except for one clinic in El Paso and I’m not sure if it’s currently open or not. I’ve been hearing mixed things. But there’s nothing in Lubbock, in Midland, in Odessa. And this impacts the people living there — women of color, people without resources.”

In other words, exactly who stands to be hurt the most on a national scale should Roe fall.

“What we’re talking about are intersectional barriers,” Kumar said. “And in the Rio Grande, even before someone realizes they need abortion care, there are so many systems at play working against them.”

Women from the Rio Grande Valley in Texas protest Judge Brett Kavanaugh’s nomination. National Latina Institute for Reproductive Health

Women in the Rio Grande Valley are mainly women of color, largely from Mexico or Central America. Many are immigrants or have immigrant backgrounds. Some are undocumented immigrants, but the vast majority are not, Kumar said. The biggest commonality, however, is that these women are largely low-income and, having been raised in this part of Texas, have had access to “not the best” public schools and “no exposure to sex ed.”

Those factors, coupled with a high uninsured rate for the region, means that individuals there are already not familiar with the health care system and what it means to interact with it, and how to go about accessing care first and foremost, yielding worse health outcomes. Food and housing insecurity are also high there, meaning that when it comes to accessing abortion care, all these other barriers presented through a person’s daily lived experience must be overcome first.

“Those who have privilege will always be able to access abortion,” Kumar said. “They will fly to where it’s legal and they can get child care and take time off of work and have been able to do so for decades. But those who have other barriers to overcome probably can’t overcome these barriers put before them there.”

While the women of the Rio Grande Valley are frequently marginalized, their lives are not insignificant. And neither are their voices. Jessica González-Rojas is the executive director of the National Institute for Latina Reproductive Health, which organizes in the region to help the women of the Rio Grande circumvent some of these barriers as best they can.

“Texas is a state where about 40% of the population are Latino,” she said. “There are 2.5 million Latinas of reproductive age in Texas. And nationally, the average age of Latina women is 28. So issues that impact reproductive justice also impact Latina lives. We are in our reproductive ages and these are the services we need.”

Texas also has the highest uninsured rate in the country, with approximately 24% of all women of reproductive age presently uninsured, Gonzalez-Rojas added.

Diana Thu-Thao Rhodes, the director of public policy at Advocates for Youth, echoed this, explaining that when girls and women are not receiving the information that is necessary to make healthy decisions about their reproductive health and lives, they’re being disserved.

“We’re setting them up. Not only do they not have access to comprehensive sex education in the state, but also in the Rio Grande Valley, they have no access to care like STI and HIV screenings or pregnancy tests,” she said. “We know basic contraception is at risk, and if a young person wants to access those services or end a pregnancy, these services are even further lacking.”

After Texas’ restrictive H.B. 2 laws were struck down by the Supreme Court in June 2016, the reality of access to reproductive health care, including abortion care, in the Rio Grande Valley is still “dire” because the area is “so rural, low-income and an under-resourced community.” Despite these challenges, González-Rojas insisted that the women of the Rio Grande are empowered and vocal advocates for their health and lives of their children and families.

“The young people we work with are first and foremost incredibly fierce activists. Not only do they have to do double-duty of educating themselves to get the education and resources they need to make responsible and healthy decisions, but then they’re also educating peers and making sure their peers have this information, too,” Rhodes said of the young adults that Advocates for Youth works with.

Rhodes said that following the reproductive health care journey of any person in the Rio Grande will tell you everything you need to know about the challenges faced there — and what the future could hold for others in places equally hostile to reproductive health, depending on how the balance of the Supreme Court falls.

“Imagine having a lack of sex ed and wanting to receive not only the education and information you need, but also the right to get medically accurate information and resources to know where to get those services,” Rhodes said. “That’s their real life.”

In the Valley, the NLIRH also works to build up education and awareness, on everything from how to identify a fake clinic to how voting impacts reproductive health care access.

“We’re trying to connect the dots for people. You see your clinic has closed? Now ask, ‘Who is to blame?’ Well, it’s the people in Austin who were elected by us. And they decided they devalued women’s health and rights and these are the repercussions and you get to speak truth to power through elections,” González-Rojas said, summarizing some of NLIRH’s messaging and work in the region. “We’re nonpartisan, so we just say, ‘You need to vote and your voice matters.’”

In the Rio Grande Valley, groups such as NLIRH work to help train promotoras, who become peer health educators in their own immediate communities. These women are often already trusted community members who know about health and health education and are able to gather their peers and neighbors to give them the information they need to best care for themselves and their families — the kind of information that, were it not coming from these leaders within the community, might not exist in these communities at all. It’s the kind of DIY health access and service that might become the norm in huge portions of the country should Roe fall.

“[Through the promotoras] you have this entry point of health access, and then you can move towards people understanding their own self-worth and value in society,” González-Rojas said. “Immigrants and Latinas, we are demonized with all the xenophobic stuff that is being said by a lot of people, including those in power. ... So reminding [these women] that you’re wonderful and the conditions you live in are not your fault but have been created by society, and when women see their self-worth and their self-power, they are so inspired.”

It’s the kind of awakening that’s been so well-documented by the coverage of the women’s movement since the election of President Donald Trump, but has been happening in the Rio Grande for some time. There, the drive to be empowered hasn’t been stoked by a new threat, but well-developed by constant, systemic barriers to health, and in turn, life.

Nonetheless, Gonzalez-Rojas said she is concerned about what the confirmation of Kavanaugh will mean to this community and their already fraught access to reproductive health care.

“I know those in power are looking to stay in power,” she said. “This [Supreme Court seat] is one way to do that, but we hope, and are out there screaming, yelling, fighting, showing up at their offices to say, ‘We flew thousands of miles to be here and we have a voice and we will keep fighting.’”