Migrant Health Issues
food insecurity, p. 760
health disparities, p. 759
migrant farmworker, p. 755
Migrant Health Act, p. 757
migrant health centers, p. 757
migrant lifestyle, p. 755
occupational health risks, p. 758
pesticide exposure, p. 759
political advocates, p. 764
seasonal farmworker, p. 755
traditional beliefs and practices, p. 762
—See Glossary for definitions
Marie Napolitano, PhD, RN, FNP
Dr. Marie Napolitano is an associate professor and the Director of the Doctor of Nursing Practice/Family Nurse Practitioner Program at the University of Portland. She has 22 years of clinical practice with migrant farmworkers and their families and has been a co-investigator on NIH pesticide exposure studies. Her areas of expertise include nurse practitioner education in the United States and internationally and the integration into practice of cultural considerations regarding immigrant and Latino populations. Her clinical interests include chronic illness self-care management for Latino individuals and families. She is Chair of the Migrant Clinician’s Network Board and a member of the American Public Health Association’s Caucus on Refugee and Immigrant Health.
Imagine yourself attempting to deliver treatment in a migrant camp to a toddler whose pertussis culture returned positive. The camp is located in an isolated rural community. The toddler lives in a trailer with her parents and siblings and extended family members (13 individuals). The family must also be treated as contacts. No one speaks English, so you have an interpreter with you. The family is just returning from picking strawberries all day in the fields, and they are tired and hungry. The family is willing to give medicine to the toddler because she is sick; however, they do not understand why they must take the medicine also, because they are not sick. The family tells you that they will not be able to take the noon dose because they have no water with them at work. Walking to the drinking barrel will take too long and they will lose income. As a nurse, what would you do? As a starting point, nurses need to be informed about the cultures, lifestyle, and health picture of the migrant and seasonal farmworkers and families that they serve.
Migrant and seasonal farmworkers (MSFWs) are essential to the agricultural industry in the United States. Although the availability and affordability of food in the United States depend on these individuals, their economic status and social acceptance have not reflected the importance of their work. Estimates of the numbers of MSFWs in the United States vary with the most commonly cited range between 3.0 and 4.5 million. Numbers vary because of differences in definition of migrants, divergent methodologies for estimating numbers, and difficulties in counting mobile populations. Standardized methodology for counting the farmworker population, developed by Dr. Alice Larson, has been used in 13 states with larger numbers of MSFWs. The majority of MSFWs are foreign born and predominantly Mexican (75%) (NCJN, 2009a). Traditionally, Mexican MSFWs have come from the west central states of Guanajuanto, Jalisco, and Michoacan; however, in 2009, 19 percent of MSFWs the non-traditional sending states of southern Mexico including Oaxaca, Guerrero, Chiapas, Puebla, Morelos and Veracruz (NCFH, 2009a “Migrant and seasonal farmworker demographics). Other workers include Central Americans, African Americans, Jamaicans, Haitians, Laotians, and Thais. The composition of the migrant and seasonal population can vary from region to region in the United States. Of the MSFWs, 47% are American citizens, legal permanent residents, or authorized to work in the United States (USDOL, 2005). Foreign-born farmworkers have spent an average of 10 years working in the United States. Approximately 29 percent have been in the United States for at least 14 years whereas 17 percent have been in the country for less than a year (NCFH, 2009a).
The definition of a migrant farmworker may vary depending on the level of government agency and by the type of service program. Federal statutes define a migrant farmworker as an individual whose principal employment within the past 24 months is in agriculture on a seasonal basis and who establishes for the purpose of such employment a temporary abode. Seasonal farmworkers work cyclically in agriculture but do not migrate. Although migrant and seasonal farmworkers comprise two distinct populations, they do share many demographic, cultural, and occupational characteristics. Much of the available information on agricultural farmworkers does not distinguish between migrant and seasonal farmworkers. Approximately 42% of hired farmworkers are migrants, but the numbers of migrants are decreasing as seasonal farmworker numbers are increasing (USDOL, 2005).
According to the National Agricultural Workers’ Survey (NAWS) (USDOL, 2005), MSFWs are young with an average age of 33 years; 31% are less than 25 years of age. Interestingly, considering the nature of the work, 18% of MSFWs are older than 45 years of age. The majority of MSFWs are male (79%); they are married with an average of two children. Approximately two thirds of married migrant farmworkers based in the United States and 15% of those coming from another country are accompanied by family. The majority of MSFWs (81%) speak Spanish as their native language with nearly half unable to speak or read English. The average school grade completed is seventh grade, with 56% of U.S.-born farmworkers and 6% of foreign-born farmworkers completing the twelfth grade. In comparison, the recent Migrant and Seasonal Farmworker Descriptive Profiles Project (MCN, 2010) found more single men; fewer women and children (except on the West Coast); an increase in seasonal workers who no longer migrate; greater representation from Central America, the Caribbean, and Pacific; and shifting industry reducing traditional labor crops with less processing. Some regional results were that housing varied in terms of availability and quality, more indigenous individuals were found in the West with corresponding language challenges, and greater labor shortages exist in the West.
Migrant farmworkers traditionally have followed one of three migratory streams: Eastern, originating in Florida; Midwestern, originating in Texas; and Western, originating in California. However, as workers increasingly travel throughout the country seeking employment, these streams are becoming less distinct. Migrant farmworkers are employed in fruit and nut (34%), vegetable (31%), horticultural (18%), field (14%), and miscellaneous (4%) agricultural venues (NCFH, 2009a). The cyclic nature of agricultural work along with its dependence on weather and economic conditions results in considerable uncertainty for migrant farmworkers. These individuals and families leave their homes with the expectation of work at certain sites. Word of mouth from friends or family, newspaper announcements, or previous employment help determine their destinations. However, upon arrival migrant farmworkers may find that other workers have arrived first or that the crops are late, leaving the farmworkers unemployed.
The way of life for a migrant farmworker is stressful. Some of the challenges of the migrant lifestyle are leaving one’s home every year, traveling, and experiencing uncertainty regarding work and housing, isolation in new communities, and a lack of resources. The average farmworker spends approximately 6 months per year doing agricultural work, 8 weeks doing non-agricultural work, 8 weeks on the road, and 10 weeks of unemployment (NCFH, 2001). Farmworkers usually are paid an hourly rate (average $7.25) followed by piece rate pay. The specifics change depending on the location and type of work.
Reports of average income for farmworkers have differed. The NAWS reported approximately 75% of MSFWs earn less than $10,000 per year and 60% of farmworker families have income totals below the federal poverty level.
Laws, such as the Fair Labor Standards Acts and the National Labor Relations Act, have been enacted to protect workers’ rights (e.g., overtime pay, minimum age of employment). However, agricultural workers are exempt from these laws as well as from some Occupational Safety and Health Administration (OSHA) protective provisions. Where laws do exist to protect agricultural workers, they may be minimally enforced.
Migrant and seasonal agricultural workers are considered a unique vulnerable population because of their mobility, physical demands of work, social and often geographic isolation, language differences, and high rates of financial impoverishment (NCFH, 2009a). Although MSFW problems are numerous and creating solutions is difficult, some progress has been made in improving the condition of the farmworker population.
Migrant farmworkers often have trouble finding available, decent, and affordable housing. Housing conditions vary between states and localities, and housing arrangements and locations and types of housing differ for migrant and seasonal farmworkers. Housing for migrant farmworkers can be located in camps with cabins, trailers, or houses and be near farms. The author has seen migrant farmworker families living in cars and tents when housing was not available. The Housing Assistance Council (HAC), a non-profit organization whose mission is to improve affordable housing in rural areas, surveyed 4600 farmworker housing units across the country and found 52% of these units to be crowded by federal standards. More than half of the units lacked showers, a laundry machine, or both (Culp and Umbarger, 2004). This prevented farmworkers from removing pesticides from themselves and their clothing in a timely manner.
Because housing may be expensive, 50 men may live in one house or three families may share one trailer. Almost one third of migrant workers paid more than 30% of their total income for housing; those in the Western stream paid up to 43% of their total income. Many also support a home-base household. In addition to crowded conditions, housing may lack individual sanitation, bathing or laundry facilities, screens on windows, or fans or heaters. Housing may be located next to fields that have been sprayed with pesticides or where farming machinery poses a danger to children. Federal and state programs provide insufficient funds to meet the demand for farmworker housing.
Health and Health Care
The literature provides only a glimpse into the health status of migrant farmworkers. National data needed to present a clear picture of their health status are unavailable. Regional and local cross-sectional health status studies allow some insights. In the past, the most inclusive health data came from two reports from California: Suffering in Silence: A Report on the Health of California’s Agricultural Workers (Villarejo et al, 2000) and the California Institute for Rural Studies (CIRS) Agricultural Workers’ Health Study (Ayala et al, 2001). These reports showed a population at high risk for chronic disease, poor dental health, and mental health problems; higher rates of certain diseases such as tuberculosis (TB), anemia, diabetes, and hypertension; high levels of work injuries and chemical exposures; and detrimental physical and social environments for the children. Accurate morbidity and mortality data are difficult to obtain because of such factors as Mexican-born farmworkers returning to Mexico when no longer working, those farmworkers going back to Mexico to receive services, and easy-to-record infectious diseases decreasing (Villarejo, 2003).
Access to Health Care
The Migrant Health Act, signed in 1962, provides funds for primary and supplemental health services to migrant workers and their families. These funds are dispersed to 154 migrant health centers in 42 states that serve as models for delivery of services to a difficult-to-reach migrant population. Migrant health centers serve more than 760,000 individuals across the country (HRSA, 2008). However, estimates show that these clinics serve less than 20% of the entire migrant farmworker population (NCFH, 2005a). The others will seek medical care from an emergency department primarily or from a private physician, or they will not seek help at all.
Migrant farmworkers have limited access to health care. One survey indicated that one third of male farmworkers had never been to a physician or clinic and half had never been to a dentist (Ayala et al, 2001). Financial, cultural, transportation, mobility, language, and occupational factors are frequently cited as the major barriers that limit access to health care for farmworkers.
• Lack of knowledge about services. Because of their isolation, migrant farmworkers lack the usual sources for information regarding available services, especially if they are not receiving public benefits.
• Inability to afford care. The Medicaid program, which is intended to serve the poor, often is not available to migrant farmworkers. Workers may not remain in a geographic area long enough to be considered for benefits or they may lose benefits when they relocate to a state with different eligibility standards. Their salaries may fluctuate each month, making them ineligible during the times their salaries rise. Employers may not offer health insurance. Therefore, migrant farmworkers lack health insurance and state program assistance, which further hinders their access to care (Box 34-1).
• Availability of services. Immigrants are treated differently, depending on whether they were in the United States before the welfare reform legislation of 1996, and depending on the category of their immigration status. Each state determines whether to fill any or part of the services’ gap to immigrants. As a result, many legal immigrants and unauthorized immigrants are ineligible for services such as Supplemental Security Income (SSI) and food stamps.
• Mobility and tracking. While migrant families move from job to job, their health care records do not typically travel with them, leading to fragmented services in such areas as TB treatment, chronic illness management, and immunizations. For example, health departments are known to dispense TB medications on a monthly basis. Adequate treatment for TB requires 6 to 12 months of medication. The migrant farmworker who relocates must independently seek out new health services in order to continue medications. The Migrant Clinicians’ Network (MCN) TB tracking program makes available to a farmworker’s current provider any previous provider information that was entered into the tracking program. This tracking helps maintain continuity of TB care for a mobile population (MCN, 2005).
• Discrimination. Although migrant farmworkers and their families bring revenue into the community, they are often perceived as poor, uneducated, transient, and ethnically different. These perceptions foster attitudes and acts of discrimination against them.
• Language. The majority of migrant farmworkers speak another language as their first language, mostly Spanish, with a growing number speaking dialects. Although migrant health centers may hire bilingual staff, many emergency departments and private physicians’ offices do not.
Occupational and Environmental Health Problems
Agricultural work ranks as one of the most dangerous industries in the United States (Worker Health Chartbook, 2004). Agriculture has the highest fatality rate for foreign-born workers (AFL-CIO, 2005). Working conditions, such as standing on ladders, being exposed to chemicals, and using machinery, produce occupational health risks for the migrant farmworkers who may be inadequately protected or educated. Lack of a comprehensive surveillance system makes it difficult to know the extent of all injuries within the migrant population. Injuries are unreported by farmworkers themselves for fear of loss of work and deportation. Injuries such as sprains and strains, fractures, and lacerations are the most common (Cooper et al, 2006). Other injuries include amputations; crush injuries from tractors, trucks, or other machinery; acute pesticide poisoning; electrical injuries; and drowning in ditches. Safety practices help prevent injuries; however, one study in North Carolina found that safety regulations are not consistently met especially during the middle of the season and that farmworkers tend not to practice safety behaviors, especially undocumented farmworkers (Whalley et al, 2009). This may be due to lack of knowledge, fear of losing time to work, or beliefs regarding who may be harmed.
The physical demands of harvesting crops 12 to 14 hours a day take their toll on the musculoskeletal system. Stooping to pick strawberries, reaching overhead while on a ladder to pick pears, or lifting heavy crates with straight legs all cause musculoskeletal pain. In one study, prevalence of chronic back pain among farmworkers and family members was 33% during the last migrant season (Shipp et al, 2009).
Naturally occurring plant substances or applied chemicals can cause irritation to the skin (contact dermatitis) or to the eyes (allergic or chemical conjunctivitis). The Bureau of Labor Statistics (2003) reported that farmworkers who work with crops have the highest incidence of skin disease of any industrial worker. Although skin diseases are common, farmworkers seldom seek care from health centers and mostly use self treatments (Feldman et al, 2009). Pesticides are found in both living quarters and the workplace of farmworkers. Pesticides include insecticides as well as pests such as insects, mice, and other animals and unwanted weeds, fungi, or microorganisms such as bacteria and viruses (Arcury and Quandt, 2009). Infectious diseases caused by poor sanitary conditions at work and home, poor quality drinking water, and contaminated foods take the form of acute gastroenteritis and parasites. Farmworkers have several risks for eye injuries because of the lack of eye protection devices, lack of knowledge about prevention of eye injuries, taking risks to save time (Verma, Schulz, Quandt et al, 2011) and exposure to chemicals, pollen, and dust. Heat-related deaths for crop workers exceed other types of workers (Luginbuhl et al, 2008). Cancer is another cited but not well-documented health problem for migrant farmworkers, mainly related to their exposure to chemicals. A high prevalence of breast cancer, brain tumors, non–Hodgkin’s lymphoma, and leukemia has been found in agricultural communities (Larson, 2001; Ray and Richards, 2001). A registry-based case-control study of breast cancer in farm labor union members in California found that one crop (mushroom) and three chemicals (an organophosphate, malathion, and an organochlorine) were associated with breast cancer risk (Mills and Yang, 2005).
The vast majority of the North American food supply is treated with pesticides. Organophosphate pesticides make up the largest group of pesticides in current use. These pesticides are known to be potential hazards. Farmworkers are exposed not only to the immediate effects of working in fields that are foggy or wet with pesticides, but also to the unknown long-term effects of chronic exposure to pesticides. The location of the migrant farmworker’s dwelling near fields or orchards can also be a major source of contamination for the worker and his or her family. The Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OHSA) require that farmworkers be given information about pesticide exposure safety. However, migrant farmworkers may not receive this information, they may receive ineffectual training, or they may not understand the information (Napolitano, Philips, and Beltran, 2002; Whalley et al, 2009).