Migrant farmworkers: Medical care for an invisible population
■ Demanding jobs and poor living conditions increase these workers’ risks of developing chronic diseases and acute illnesses, yet too few receive health care.
During the summer, internist Bruce Gould, MD, drives to the farm fields that stretch across Connecticut to see his patients. He arrives at night after the migrant farmworkers have finished harvesting tobacco.
He examines them behind barns, at picnic tables or in makeshift exam rooms that consist of a folding massage table and a tarp roof.
Some nights, he finds people hiding in nearby bushes. They often are desperate for medical care but fear they will be fired if their foreman finds out they are sick. Dr. Gould assures them, “Whatever we find is kept between us. I’m here for you.”
The doctor helped establish the University of Connecticut’s mobile Migrant Farm Worker Clinic in 1997 to bring medical care to a severely underserved population. From June through October, medical students and physicians affiliated with the university volunteer at local farms, and try to manage chronic diseases, treat infections and mend injuries.
“Part of what we’re trying to teach is that all people deserve care,” said Dr. Gould, associate dean for primary care at the University of Connecticut School of Medicine.
Anywhere from 1 million to 3 million migrant and seasonal farmworkers harvest crops across the U.S. each year. Migrant farmworkers typically travel within a state or across states, following crops for harvest. Seasonal workers typically stay in one area.
Due largely to the demands of their jobs and poor living conditions, migrant farmworkers have higher rates of work-related injuries, chronic conditions, acute illnesses and infectious diseases compared with other populations, according to the Texas-based National Center for Farmworker Health. The organization seeks to improve farmworker families’ health.
Complicating matters is the fact that farmworkers often are impoverished, uninsured and foreign-born, which means many face financial, cultural and language barriers to receiving health care, the center says.
Although the University of Connecticut’s clinic has improved health for these workers, there still are too many without regular medical care, Dr. Gould said. On a national level, migrant health clinics serve only about 13% of the intended population, according to the Centers for Disease Control and Prevention.
Part of the problem is that many migrant workers do not know the clinics exist. There also are too few physicians who care for this population, due, in part, to concerns about not getting paid for treating patients who often are uninsured.
“I understand why so many doctors aren’t doing this. There are a lot of systemic barriers they have to face. But those doctors need to ask themselves, ‘What can I do to be part of the solution?’ ” said Jennie McLaurin, MD, MPH, a pediatrician who treated migrant workers and their families in North Carolina.
Dr. McLaurin now works as a specialist in child and migration health and bioethics for the Texas-based Migrant Clinicians Network, which helps physicians treat that population. “We all have a responsibility to care for anyone in our midst who needs health care, regardless of their ability to pay, immigration status, ethnicity, race or sexuality.”
Obstacles that keep farmworkers from care
Scattered across the country are about 159 migrant health centers, which are partially funded by federal grants, according to the National Center for Farmworker Health. In Louisiana, there is only one such clinic. It sits in the rural town of Independence, which is tucked in the southeast corner of the state near the Mississippi border.
Internist George Keshelava, MD, is the only physician on-site. He cares for patients with the help of nurse practitioners.
Although many of the migrant farmworkers he sees are relatively young, they often have diabetes, hypertension and metabolic conditions. Chronic diseases tend to develop earlier among this group, because many are too poor to buy nutritious food and few receive preventive care, health professionals say. In 2000, only 20% of migrant and seasonal farmworkers reported using any health care services in the past two years, according to a 2005 report by the Kaiser Commission on Medicaid and the Uninsured.
“It’s an unfortunate situation. They need access to care, and they are reluctant to seek care,” said Dr. Keshelava, medical director at Multipractice Clinic in Independence.
Lack of health insurance and transportation often contribute to their hesitancy to see a doctor. Other concerns include being fired for taking time off work and getting reported to immigration services if they are in the U.S. illegally.
About half of the nation’s migrant farmworkers are undocumented, health professionals say. The H-2A temporary agricultural program allows farm employers who anticipate a shortage of U.S. workers to hire people from other countries for temporary farm work, said the U.S. Dept. of Labor Employment and Training Administration.
“Much of the rhetoric around farmworkers is sort of dehumanizing,” said Virginia Ruiz, director of Occupational and Environmental Health at Farmworker Justice. The Washington-based nonprofit aims to improve the lives and working conditions of migrant and seasonal farmworkers. “People talk about them as if they’re not deserving or don’t have a right to health care. They are human beings and they are working very hard in a very hazardous industry.”
Dealing with injuries
Agriculture is one of the nation’s most dangerous professions. In 2009, there were 24.7 work-related injury deaths per 100,000 farmers and farmworkers, the CDC said. That same year, the overall U.S. rate of fatal occupational injuries was 3.5 deaths per 100,000 full-time workers, according to the Dept. of Labor.
Just as serious are accidents that cause significant injury and poor health, said Jerry Williamson, MD, chief medical officer at the Healthcare Network of Southwest Florida in Immokalee.
The nonprofit cares for all patients regardless of whether they are insured.
Dr. Williamson often sees migrant farmworkers injured from falling off ladders while picking citrus fruit or carrying heavy baskets filled with produce. He also frequently treats eye injuries caused by exposure to pesticides or abrasions from thorns, stalks and vines.
Other unique occupational hazards cause medical problems. For example, some workers develop urinary tract infections because they have limited time during the day to use the bathroom and get heat stroke due to long hours in the sun.
“I’ve seen women who were pregnant carrying baskets that I think most men wouldn’t be able to carry, and they do that multiple times throughout the day,” Dr. Williamson said.
Managing the health of these workers is challenging not just because of the multitude of their medical problems, but also because many do not take their medication properly, said internist Jose R. Quero, MD, chief of adult medicine for the Healthcare Network of Southwest Florida.
Most workers don’t get breaks, so they must take their medication in the fields. That can be awkward for patients with diabetes, who have to inject themselves with insulin while working, Dr. Quero said.
Some patients never purchase their medication because they can’t afford it. Others don’t understand how to take the drugs due to limited education. Even if patients take their medication, physicians often can’t follow up with them, because many move suddenly to the next town or state to harvest crops.
Exacerbating the problem is that doctors have little way of knowing what type of medical care patients receive when they leave.
“I have a blueberry picker who left for Indiana to go to the blueberry fields,” Dr. Quero said. “He didn’t get care for three years, and when he came back, he was sick as a dog. We see this all the time.”
Despite such challenges, Dr. Quero and other physicians say the job is rewarding.
“I am an immigrant to this country, and I feel very fortunate to have received the opportunities and education I received,” said Dr. Quero, who was born in Cuba. “I believe that somewhere along the line you have to give back.”
Doctors realize there are limits to how much they can help these patients, particularly if they need a specialist.
Dr. McLaurin, of the Migrant Clinicians Network, recalled a 2-year-old child of a migrant farmworker in North Carolina who had a hip abnormality that required orthopedic surgery. The local hospital, however, would not operate because the family was uninsured and could not pay for the procedure.
The boy developed a painful limp and could be disabled for life without the procedure.
“We came up against those situations a lot,” said Dr. McLaurin, who teaches medical students and health professionals how to address health disparities among migrant farmworkers and their families.
She encourages physicians to focus on what they can do for patients rather than become overwhelmed by what they can’t accomplish. They can take simple steps such as advocating in their community for changes to improve health care for migrant farmworkers and their families.
“I personally have to feel like I’m doing all the good I can do with the gift that has been given to me,” Dr. McLaurin said. “But I recognize that I can’t do everything.”