Access To Healthcare MSFW’S In Oregon And Washington

Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

Review of the Literature about Access to Health Care for Migrant & Seasonal Farm Workers (MSFW’s) and their Families in the State of Oregon

HE 407 Migrant Health Final Paper

Shannon Paris Oscar Ramos

Professor – Daniel Lopez-Cevallos PhD

December 4, 2008

Review of the Literature about Access to Health Care for Migrant & Seasonal Farm Workers (MSFW’s) and their Families in the State of Oregon HE 407 Migrant Health Final Paper – December 2008 Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

INTRODUCTION

In a few more days most of us will once again take out our best holiday decorations, will wear our best clothes and will sit down to eat a grandiose meal or meals, as we reflect the end of hopefully another prosperous, healthy and productive year. As we give thanks around the table among our family and friends, we invite you also to thank a nearly invisible group of people who has worked diligently throughout the year, so we can have at our disposition delicious, healthy and affordable, fruits, vegetables, wines, meats, flowers, trees and other radiant comestibles and decorations harvested from our bountiful lands. This faceless group of people, who probably will not be able to eat the food that will be in front of us, which they worked so laboriously to produce, or decorate their own front door (assuming they have one) with a wreath, as themselves they may not be able to afford them, are the millions of migrant and seasonal farm workers diligently pacing the agricultural fields of America.

Migrant and Seasonal Farm Workers (MSFW’s) are undoubtedly an indispensable asset to the U.S. multibillion dollar agricultural industry, which in regards to the Pacific Northwest, is one of the primary industries that support the State of Oregon. Due to the nature of their work, this population has an elevated risk of poor health, so they could certainly benefit tremendously from doctor visits and medications. Unfortunately, these disadvantaged groups of people and their families have a major problem that compounds exponentially that elevated risk of poor health. Most of them lack availability and accessibility to affordable health care services.

The purposes of this paper are to review the relevant literature that addresses the contributing factors to their poor health outcomes and their inabilities they have to get the care due to the vulnerabilities they affront, the barriers that prevent them from accessing health care Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos services, the racial/ethnic disparities they are subjected to, the myths and facts about their use of our health care system, as well as the health risks they are exposed to. To begin we will first review some information in regards to who they are, where they come from, and what they do for the economy of Oregon and the U.S. overall. Then we will discuss the health situations as delineated above, and then we will discuss some of the recommendations we should present to our legislators to pass new laws, for institutions to implement and for our enforcement agencies to regulate to help this significant population of our country have better health outcomes.

Historical Perspective

A good population study should begin with a foundation of where the study group comes from so we start here. The State of Oregon has been for many years considered a primary Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos receiving state for MSFW’s. A document that provides great documentation about this argument is the very comprehensive report compiled by the University of Oregon titled “Understanding the

Immigrant Experience in Oregon” This report provides a solid foundation about the history of immigration to Oregon, reasons why it is such a gateway for immigrants, where most of them come from, detailed demographics and were they most find employment and in what industry.

Some specific sections from that report that address the historical perspective of MSWF’s in the state are the following:

 Oregon has seen significant increases in immigrants from Central & South American

countries, mostly from Mexico (page 28).

 During the Bracero Program of 1942, thousands of Mexican workers were recruited from

Mexico to come to work into the agricultural fields of the U.S. as our workforce was

fighting a world war in two fronts. This program lasted from 1942 until 1964, which

created a “pipeline” for Mexican MSFW’s to come to Oregon due to familial

reunifications, settling mainly in areas with large agricultural populations such as

Woodburn, Independence and Nyssa (page 28).

 Following “frequent abuse” from land owners and “tense” community relationships,

many groups of MSFW’s created organizations and institutions that would help them live

a more fair life in Oregon (page 28). Out of this many new institutions, an “aggressive

and energetic farm workers union” came about called, Pineros y Campesinos Unidos del

Noroeste – PCUN (Northwest Treeplanters and FarmWorkers United. This institution is

now Oregon’s largest Latino organizations, which is labor union for farmworkers,

nursery, and reforestation workers. Founded in 1985 by 80 farmworkers, PCUN has

since grown to include more than 5,000 registered members, 98% of which are Mexican Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

and Central American immigrants, and to encompass a wide variety of organizing

projects. (PCUN Website)

 Following devastating U.S legislations in the 1960’s and 1980’s that deported millions of

workers, which were created to curb the flow of Mexican immigrants into America, many

more MSFW”s came still into the country as such legislation could not deter them from

securing a better here (page 29). Furthermore, a major flow of indigenous workers from

the state of Oaxaca in Mexico have swelled Oregon’s MSFW’s population during the last

few decades. Their numbers increased further after the passage of the North American

Free Trade Agreement (NAFTA) which raised food prices in their homeland. Many of

these MSFW’s are contracted to work in a circular pattern around the states of California,

Oregon and Washington. Their primary ethnic background is Triqui and Mixtec (page 48)

and as non-Spanish speakers, they affront additional problems within their “society”.

Background Information

The Migrant Clinicians Network (a clinical network for the mobile underserved) states in their website that the “United States Public Health Service estimates a total of 3.5 million migrant and seasonal farm workers in the United Sates” This same sentence was repeated more Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos than 20 times in additional websites devoted to MSFW’s or situations related to groups close to them. It was linked to many websites and from many websites, but sadly the only place we could not find this important factual piece of information was with the website of the United States

Public Health Service itself. As we found the number referenced to a document published in

1984 titled “An overview of the growth and development of the U.S. Migrant Health Program” we would predict to say that this latest “estimated” number is too low to do justice to the actual numbers. Many other sources gave numbers as low as 1.5 million up to 5 million. We could not find the most accurate answer, but based on what the other organizations have accepted, we reluctantly have to keep the 3.5 million.

That point aside, as applicable to Oregon, “actual numbers” of total MSFW’s in the state are “best” retrieved from the Migrant and Seasonal Farmworkers Enumeration Profiles Study –

Oregon, (OR-MSFW-EPS) conducted by Alice Larson, PhD, in 2002. Doctor Larson, who resides in the State of Washington, is one of the nation’s leading researchers on farmworker issues. She has conducted similar enumeration profile studies in most states that have large populations of MSFW’s such as OR, WA, CA, FL, TX, MN, MI, as well as other pertinent projects in regards to their health outcomes. She uses a “Demand for Labor Method (DFL)” which has been described by various sources as being a very accurate method to account for multiple factors, being more effective than traditional methods such as only using monthly farm surveys. The DFL process examines the number of workers needed to perform temporary agricultural tasks, primarily harvesting, although activities are also estimated including pruning, weeding and thinning operations where extensive hand labor is involved. Using this approach than she makes estimates depending on FTE’s needed for each crop and for each county (OR-

MSFW-EPS). As background information to her study, she states that “Estimating MSFW’s is Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos extremely difficult, and no current source provides reliable information, particularly for population figures at the county level” Prior to her report, the last time a similar study was conducted, although not as inclusive, was in 1990 when Oregon was included in a 10-state report conducted by the U.S Department of Health & Human Services titled “An Atlas of State Profiles

Which Estimate Number of Migrant and Seasonal Farmworkers and Their Families”. Dr.

Larson’s final report provided the following figures and estimates:

 There are an estimated 174,484 MSFWs and their families living in Oregon, broken

down in the following sub-groups:

o Migrant workers - 39,000

o Seasonal workers - 63,554

o Members of their family - 71,030

 Children of MSFW under the age of 20, resulted in:

o Migrant children and youth – 14,558

o Seasonal children and youth – 44,905

 The major MSFW concentrations are found in the Northwest part of the state around the

Willamette Valley, in the Hood River Valley, the Columbia River Basin, Southern and

Southeastern Oregon.

 The main agricultural products of the state include a wide variety of vegetables, fruits,

dairy products, livestock, hops, wine, Christmas trees, nursery products, bulbs, etc.

Additional all-inclusive factors can be obtained from the project named “Findings from the

National Agricultural Workers Survey (NAWS) 1997- 1998: A Demographic and Employment

Profile of United States Farmworkers”, conducted and published by the U.S. Department of

Labor and published in March 2000. This survey is also now ten years old, but as it is the only Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos source with such numbers, it remains the most accurate document with this information that we can use at this time. Some of the more relevant findings of this survey in regards to MSFW’s are the following:

 Place of Birth and Length of Stay in the U.S.

o 81% of all farm workers in 1997-98 were foreign-born

o 77% of all farm workers were Mexican-born

o Foreign-born farm workers had spent an average of 10 years in the U.S.

 Demographics, Family and Household Composition

o Farm workers are young; their average age is 31, and half of all farm workers are

under 29 years of age

o 80% of all farm workers are men

o 52% of all farm workers are married, 43% singles, while the remaining 5% were

widowed, separated or divorced

o Among farm worker parents, half are not accompanied by their children

 Education, Literacy and English Skills

o 84% of farm workers spoke Spanish

o Farm workers typically had completed 6 years of education

o Just 1/10 of foreign-born farm workers spoke or read English fluently

 Labor

o 60% of all farm workers held just one U.S. farm job per year

o During the course of the year, they spent approximately half of their time doing

farm work Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

o 56% of all farm workers migrate, whether within the United States and/or

internationally

o 52% of farm workers lacked work authorization, 22% were citizens, and 24%

were legal residents. The rest were students, refugees and asylees.

 Characteristics of Farm Jobs and Farm Conditions

o 19% of farm workers were employed by a farm labor contractor

o 61% worked in fruits, nuts or vegetables

o 1/3 of the jobs were in crop harvest, and 1/4 were in semi-skilled technical jobs

o Three out of four farm workers were paid by the hour, with an average hourly

wage of $5.94

o Although 20% reported being covered by unemployment insurance, just 5%

reported being covered by employer provided insurance

 Income and Assets

o Nearly 3/4 of farm workers earned less than $10,000 per year

o 3 out of 5 farm workers families had income below the poverty level

o More than half owned a vehicle

o Few workers received needs-based social services. Nearly all received food

stamps

Oregon Agriculture

The mild climate of the American Northwest provides extremely fertile lands suitable to grow a variety of products. The State of Oregon Department of Agriculture expresses this point best in their website when they refer to the Willamette Valley, the major agricultural region Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos in the state, as being," Perhaps the most diverse agricultural region on earth–more than 170 different crops including grains, hays, grass and legume seed field crops of all kinds, tree fruits and nuts, small fruits and berries, wines, fresh and processed vegetables, Christmas trees, nursery products of all descriptions, dairy, poultry and beef are all produced in this amazing valley"

The Agri-Business Council of Oregon website and the Oregon Department of Agriculture provided the following facts about Oregon Agriculture:

 There are more than 250 diverse products grown and processed in Oregon ranging from

wheat to salmon. Only California has a higher number of commodities in the United

States.

 Oregon's top agricultural products include: milk, nursery stock, hops, cattle and calves,

berries, pears, potatoes, eggs, onions, peppermint, wine grapes, cherries, ground fish,

crab, hay and sweet corn.

 There are more than 40,000 farms in Oregon, a number that continues to grow annually,

defying the national trend. Oregon products are sought all over the world due to their

superior quality.

 The agriculture industry contributes more than $8.25 billion to our state's economy each

 Oregon was in 2007 the number one U.S. producer of: blackberries, hazelnuts,

loganberries, black raspberries, ryegrass seed, orchardgrass seed, sugarbeets for seed,

crimson clover, fescue seed, boysen and young berries, red clover seed, Christmas trees Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

and dried herbs. They are number two in 10 more products like peppermint, hops, snap

beans, spearmint, nursery crops, sweet cherries and red raspberries.

 Some 90% of Oregon's agricultural products are sent out of the state with about half that

amount exported to foreign countries.

The Role of Migrant & Seasonal Farm Workers in Agriculture

MSFW's perform very physically demanding jobs as they plant, grow, harvest, and package our fruits and vegetables. Some of the tasks performed during their grueling day are:

tilling the soil planting seeds transplanting

seedlings Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

removing weeds applying pesticides laying down pipes

staking plants pruning plants harvesting crops

packing crops preparing them for selling crops

the market.

Nick Nahmias, a renowned documentary photographer in his book “The Migrant Project”, provides a vivid description of the plight migrant farm workers face during their day; after he went to visit a tomato field in California were MSFWs were getting ready to harvest the crop:

"Getting out of the car, I was instantly overwhelmed by both the smell of hot

earth and tomato and the panorama of a literal army of men anxiously waiting

along the edges of the ten-acre field for the signal that the morning dew had dried

enough for them to begin work. This took longer than usual because of overcast

conditions, causing a delay in work, which in turn would impact potentials

earnings for the day. Thus when the signal came in the form of a tooting car horn,

the workers flooded in from all directions as if sprinting onto the field at the

conclusion of the World Cup. Men immediately dove to their knees and began

crawling through the muck and thickets of tomato plants to fill a pair of pails with Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

about twenty-five pounds each of green fruit as fast as possible. They would then

dash to the nearby open-bed semitrailers, thrust their pails above their heads, and

have the fruit emptied and replaced with a single brass token worth ninety-cents"

(Nahmias)

Situations like this will not go away, as even though farming has become much mechanized during the last 50 years or so, nothing can replace the hands of a farmer when is time to deal with soft produce such as harvesting strawberries or picking tomatoes.

Health Problems & Occupational Injuries Most Commonly Reported

MSWF's acquire a variety of acute and chronic health problems during their lifetime

(with a higher incidence than the majority of the population) which are augmented by multiple compounding barriers. Migrant workers currently suffer from mortality and morbidity rates greater than the majority of the general population in the United States. The life expectancy of a migrant farmworker is 49 years, compared to the national average of 73 (CDC 1998). The health issues faced by MSFW’s are not unlike those faced by other disadvantaged populations. Some of the health conditions they suffer from are the following:

Diabetes Obesity Hypertension Cardiovascular Parasitic Fungal Infections

Disease Infections

Asthma Deafness Cancer HIV/AIDS Tuberculosis H-pylori Infections

Anxiety Anemia Depression Substance Sleep Fatigue Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

Abuse Disturbances

Sterility Blood Malnutrition Liver Problems Kidney Dental Problems

Disorders Problems

Muscle Bone Chronic Eye

Problems Problems Dermititis Problems

On the article titled Migration, Health and Work: The Facts Behind the Myths, the authors provide good examples of how dangerous are jobs done my MSFW’s nationwide. They describe that Mexican Immigrants have a high risk of being killed or fatally injured on the job because they mainly perform farming, construction and service jobs. Numbers show that workers of farming, fishing and forestry industries (Oregon’s 3 f’s) are the most likely to suffer a fatal work related injury or illness. Sprains and strains are the most common injuries. Men MSFW’s usually suffer more injuries upon contact with hazardous objects and equipment, while females usually suffer more stretching and overextending injuries due lifting, running, slipping, pushing and repetitive motion. Farmwork accounts for 13% of all workplace fatalities, making it one of the most dangerous occupations in the US. To compound matters worse, they are exposed daily to pesticides and other chemicals that can cause serious injuries or death to them and their families.

Some of the common occupational injuries are:

Fractures Sprains / Strains Carpal tunnel syndrome

Back injuries Pesticide exposure Chemical exposure Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

Heat exhaustion Heat stroke Dehydration

Hypothermia Traumatic farm injuries Assault by others

Vulnerability & Contributing Factors to Poor Health Outcomes

MSFW’s face many obstacles and barriers in accessing health care while they are exposed to dangerous jobs and crowded living conditions, dilapidated housing, long working hours, low wages, poor or no benefits and no health insurance which promote injury, illness and poor health. Sadly, they also face vulnerability factors that increase their poor health outcomes as a population overall. The long-term consequences of neglecting this population will be indeed detrimental to the future of our nation.

 Vulnerability Factors - In the article titled “Immigrants and Health Care: Sources of

Vulnerability”, we find thorough information of some of the factors that come into place. The

authors in this article quotes from a book titled At Risk in America: The Health

and Health Care Needs of Vulnerable Populations in the United

States that “a vulnerable population is a group at increased risk for poor physical,

psychological, and social health outcomes and inadequate health care” (Derosa). This article

addresses a more broad perspective about immigrants, not focusing specifically on just

MSFW’s, but the ideas apply as well, because to no surprise to all, MSFW’s are very Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

vulnerable. Low socioeconomic status, immigration status, ability to speak English, welfare

reform, residential location, and stigma and marginalization are the discussed vulnerability

factors.

1* Poor Working Conditions - The work environment requires the employee to work excessive

long hours, in sometimes backbreaking positions. Employee training is often not offered in

the corresponding language if offered at all. Training on the proper use of equipment and

dangers of misuse or possible malfunction of equipment is essential to preventing needless

accidents and injuries. Safety training regarding the dangers of exposure to pesticides is often

not given. OSHA (Occupational Health and Safety Act) mandates that those who employ

greater than 11 persons provide toilets and hot water for hand washing. The EPA

(Environmental Protection Agency) mandates that safety training is provided in the

understood language. Many farms do not adhere to these regulations and are not discovered

to be out of compliance until a complaint is made. Due to these working conditions MSFWs

are subjected to a large number of occupational and health related injuries and suffer from

numerous acute and chronic illnesses.

2* Housing Conditions - MSFWs often have a difficult time securing adequate housing. Many

rental units have occupancy limits allowing only a specific number of tenants per square foot.

There are a limited number of units rented on a month to month basis. Standard rental rates

usually apply to whatever the regional average is at the time and do not adjust to

accommodate a population whose income is below the poverty level. As a result many

MSFWs are required to live in their vans or cars until shelter can be secured. Upon finding a

dwelling it is often overcrowded with workers, family and children traveling along. Housing

is sometimes available near the worksite but can be substandard and continues to expose the Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

tenants to excessive levels of pesticides. These overcrowded conditions contribute to the

spread of infectious and contagious diseases.

3* Poor Nutrition - Living in poverty and low Socioeconomic Status (SES) are two factors that

contribute to poor nutrition. Supplemental vitamins and gym memberships are not priorities

to those who live hand to mouth. Even with supplemental programs such as Food Stamps and

WIC (Women, Infants and Children) available resources for food are still limited. Limited

funds equal limited choices. Shoppers generally choose from main staples of nutrition such

as beans and rice or less expensive foods such as pastas and tortillas. Access to a full array of

fruits, vegetables and meats and dairy may be limited as they are more costly.

4* Perceived Racism - According to Stephanie Farquhar professor from Portland State

University Department of Community Health, those who work in the fields as crew bosses

are often the ones who demand the most of the workers. They are pushed to work harder,

faster and longer hours to meet the demands of the employers. The crew boss who should be

trusted as an advocate for the workers generally represents the interests of the company.

Illnesses and injuries go unreported for fear of retaliation and subsequent loss of

employment. MSFWs feel discriminated against by their employers, coworkers, and often in

the receiving communities where they work, live, shop and try to educate themselves and

their children. This perceived and actual racism takes its toll on the psyche of any human and

begins to diminish a persons self worth, feeling of acceptance, belonging and safety.

5* Allostatic Load - According to American Journal of Public Health and the article titled

“Approaching Health Disparities From a Population Perspective” there are contextual

stressors that lead to poor health outcomes. Allostatic load describes the body’s physiological Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

response to its environment over time. The cumulative effect of this biological stress creates

an environment conducive to cancer growth. Studies show that low SES is associated with

high allostatic load. Stress is a precursor to irregularities in multiple body systems increasing

the susceptibility to a variety of illnesses and disease. Allostatic load can be directly

attributed as a major cause of morbidity and mortality (Warnecke).

Barriers to Accessing Healthcare

6* Language - The ability to understand the English language greatly increases healthcare

accessibility. A lack of the ability to interactively communicate creates a disparity in equal

access to care. An inability to communicate ones needs, to ask questions, or to receive health

education or advice creates a handicap in this nation. Translators have helped with aspects of

overcoming this barrier but cultural incompetence and the use of children as translators can

cause vital information to be lost in translation. This has also become a more complicated

issue as new numbers show that of the 90+% that are of Mexican background, are actually

indigenous people who do not speak Spanish or English, but their local language such as

Triqui or Mixteco.

7* Education - Preventative care requires education. Education requires understanding.

Practicing safety at work and in your environment as well as practicing healthy lifestyle

choices are a learned phenomena that require reinforcement. If you are linguistically isolated

and possibly lack literacy skills your chances of maintaining healthy choices are reduced Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

dramatically. Recognizing symptoms of illnesses and relaying these symptoms to healthcare

personnel are vital to obtaining proper treatment. Understanding treatment protocols and the

importance of follow through and follow up care require proper translation.

8* Lack of Insurance - Many employers do not provide health insurance leaving the burden of

cost to the employee for any health related services obtained. As many workers are

undocumented they are not offered disability or workmen’s compensation for injuries or

illnesses acquired on the job.

9* Poverty - Due to low wages workers cannot afford doctor visits even when they are offered

on a sliding scale. Often workers may seek out several services from random different

providers according to what services are offered free or discounted. This makes continuity of

care an insurmountable task as obtaining an accurate health history complete with previous

symptoms, diagnoses treatments attempted and evaluation of outcomes will not be available

to each new provider. Some workers may lack transportation and may be secluded from the

transit system. In a video called California’s Harvest of Shame by the United Farm Workers

one can clearly see the disparities of how hard they work to how measly their salaries are. In

that video, onion pickers gather up large bags of onions for what they are paid only 80 cents.

10* Lack of Understanding of the Healthcare System – The Health Care system is difficult to

understand, even though for natives. Some of the major roadblocks that MSFW’s face are:

11* Cultural differences related to making and keeping appointments

12* Having to wait to be seen, new patient protocol and triage can discourage workers

from seeking treatment.

13* Many new patient appointments must be scheduled a month in advance. So callers

will forget. Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

14* Walking into a clinic with an acute condition does not guarantee that you will be seen.

15* Same day appointments may only be given to established patients.

16* Nurse triage may have to call a patient back to assess their illness.

17* The patient may not have their own phone.

In general our healthcare system is difficult to navigate even as an English speaker. The

programs that are available often have to be sought out by asking several pointed questions

that reception doesn’t always have the answer to. Clinics may not be open when an employee

has time to attend due to their long work hours.

A good example of what happens when the communication does not reach the MSFW’s

ears was seen in the video called “Promotoras Exchange Video” found in the website for

Health Initiatives of the Americas from the of University of California Berkeley. On this

video some promotoras of California went do an exchange of information with promotoras in

Mexico. One of the local Mexican women stated that if she “would have known anything

about family planning, I would not have popped so many children”

18* Fear of the Establishment - Many undocumented workers may fear seeking out treatment

due to their lack of documentation. They may also not want to miss work or have their boss

or coworkers know of their illness for fear of being let go. In the previously discussed video,

there are also sections were the fear that some undocumented workers face in regards to

being deported, are sometimes stringer than their actual medical condition, so they think.

19* Public Policy - According to an article published by the American Journal of Public Health

titled “Immigrant Children’s Reliance on Public Health Insurance in the wake of

Immigration Reform”, it stated that “federal state and local policies can promote or hinder

health insurance coverage for immigrants” The Personal Responsibility Work Opportunity Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

and Reconciliation Act of 1996 known as welfare reform ruled that immigrants residing in

the U.S. for less than five years were no longer eligible for public health benefits. The idea

was to decrease the possible incentives of immigration. Attitudes towards immigration and

indifference to needs of a vulnerable population can have effects on the policies written.

Misconceptions lead to the perception that our failing healthcare system is the result of

increased immigration and not the result of skyrocketing healthcare costs and a nation wide

lack of insurance.

Racial/ Ethnic Disparities

According to the The Kaiser Family Foundation article titled “Eliminating

Racial/Ethnic Disparities in Health Care: What are the options?”, disparities in health care, whether in access to care, insurance coverage or quality of care are all factors that produce inequalities in health status. Perceived needs of a patient or stereotypes related to race and ethnicity can affect quality of care. Providers may presume a patient doesn’t want to have a certain screening test done or may not bother with preventative education. Follow up care may be disregarded as well. A few keys facts related to MSFW’s form this article are the following:

o The rate of new AIDS cases in 2003 was tree times higher among Hispanics than

among whites (26 per 100,000 for Hispanics vs. 7 per 100,000 for whites)

o At least one in three nonelderly Latinos (36%) is uninsured as compared with 13% of

whites.

o Uninsured are twice as likely not to have a doctors visit in the last year.

o Children of uninsured parents often face greater risks of being uninsured because they

generally rely on their parents to obtain these benefits through work. Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

o Latino adults are less likely to rely on a private physician for their medical care than

White adults (44% vs. 77%)

There are some state programs that have tried to offset welfare reform but many immigrants do not access these programs for fear of being deported themselves. Cultural awareness regarding migrant attitudes toward healthcare, the use of natural healers, and spiritual beliefs need to be individually assessed to avoid generalizations which may hinder quality care.

Myths and Facts Related to Immigrants Use of Healthcare

In regards to Immigrants “abuse” of the U.S Health Care system, the Center for American

Progress published an article titled “Immigrants in the U.S. Health Care System: Five Myths

That Misinform the American Public” which busts many myths precluding the mind of

American citizens in regards to such issue. The article specifically addresses five of such myths which have “fed a perception that one of the biggest reasons for our nation’s failing health care system is the growth of immigration- and no the lack of insurance and skyrocketing health care costs” :

o U.S. public health insurance programs are overburdened with documented and

undocumented immigrants – This cannot happen as undocumented immigrants and

non-permanent document immigrants are restricted from accessing Medicaid, except

limited coverage for emergency services. Even documented new residents cannot

access Medicaid for the first five years of their new status since 1996 (this applies to

40% all documented permanent residents)

o Immigrants consume large quantities of health care resources – These are once Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

again inflated numbers as immigrants are more likely to be uninsured, so they are less

likely to consume health services. Nearly 44% of documented immigrants were

uninsured in 2005, which is three times the rate of the native born who are uninsured.

o Immigrants come to the United States to gain access to health care services –

Immigrants do not wake up in the morning and come to America to use our health

care system. They come because they need jobs as demonstrated by the fact that they

are employed in jobs that usually do not offer health insurance coverage such as

agriculture, construction, food processing, restaurants and hotel services.

o Restricting ‘immigrants’ access to the health care system will not affect

American citizens – If you restrict preventive care to immigrants, their health will

deteriorate and will cost more to take care of them in the future, affecting directly the

future of Americans.

o Undocumented immigrants are “free riders” in the American health care system

– Immigrants for the most part contribute more to the revenue stream for U.S social

benefits than what they use.

Furthermore, the Kaiser Family Foundation published an article titled “Summary: Five

Basic Facts on Immigrants ad Their Health Care”, which addressed similar myths about this topics. This article can be summarized in five sentences:

o The primary reason most immigrants come to the U.S. is employment, not health care

o Non-citizens are much more likely to be uninsured than citizens, but they are not the

primary factor driving the nation’s uninsured problem.

o Federal law generally bars undocumented immigrants and recent legal immigrants

from receiving Medicaid and SCHIP coverage. Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

o Non-citizens receive significantly less health care than citizens.

o Non-citizens are significantly less likely to use emergency room than citizens.

Sadly, despite this two reports published by reputable unbiased agencies, this myths still remain in the mind of American citizens, which will once again become factors in regards to new policy making against MSFW’s, as it has done in the past.

Advances/Deficits in Outreach

Certain advances have been made with the use of promotores, translators, interpreters, health care navigators, bilingual brochures with pictures, mobile health units, and cultural awareness projects to healthcare employees. Many of the funds that allow for these programs are limited and outreach efforts are usually discontinued with termination of funding. Translators and Interpreter who do not have adequate training in medical terminology or physiology of disease may not relay information thoroughly. Clinical Health Navigators may have limited access to health records hindering their ability to perform their jobs to the fullest capacity.

Miscellaneous

As final concrete examples of the problems MSFW’s face on a daily basis, we wanted to provide a few personal accounts of how already we have seen first hand how some of these problems are causing detrimental damages to the health outcomes of such individuals.

Case #1 – While working in an unnamed nursing facility, open only for non-English Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos speaking residents, the following problems were noticed. Bath time mealtime and medication administration were announced in English. Pain meds were ordered PRN, meaning as needed usually 1-2 pills every 4-6 hours. A good nurse will offer the meds as often as allowed to stay on top of the pain as it is easier to control this way versus letting the pain level reach insurmountable levels. Once pain is uncontrolled it is harder to bring it back down. As there were limited employees who spoke Spanish these patients would often go days without their pain management until they were forced to ask any bilingual employee available to relay their request to the nurse.

Sadly, Pain pills can be prescribed as mandatory which means they would be put on the

MAR (Medical Administration Record) and would automatically be given eliminating any misunderstanding. One resident in particular kept insisting that her Doctor ordered antibiotics that she was not receiving. This information was relayed to the nurse but upon my return the next week I found there had been no follow up and the patient still had no idea what was going on.

Some of the nurses were overheard discussing the non-English speaking patient’s use of

Medicaid and voicing their irritation at how this patient couldn’t have lived here long enough to pay into the system that was paying for their stay in the facility. Although there was no overt neglect personal biases were apparent.

Case #2 – Working in emergency rooms for many years I have been privileged to have been able to use my Spanish language speaking abilities to assist doctors and nurses with patient care, from their arrival into the ER up until their point of admission or discharge. This has changed recently when once again I obtained a job in another ER and I tried to use my skills to serve the immigrant population. I was told by a nursing supervisor that as I was not a “State

Certified Medical Interpreter” which our hospital does not employ one, I was not allow to Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos interpret or translate medical information to doctors or nurses, as the hospital could become liable if I messed something up. Doctors and nurse were supposed to use the local interpreting services over the phone to provide this service to patients. I have been interpreting in ER’s for about 15 years now, and as Spanish is my first language, this one was a very large pill to swallow. I have already experienced seeing patients leaving their rooms perplexed as sometimes the nurse did not get an interpreter over the phone before discharge, or the interpreter services were not up to par and the right information was not passed along.

Recommendations

Based in all the literature that we have explored we can state these are some of the recommendations given by many of the authors, to maximize better health outcomes for

MSFW’s:

 Continue to increase public awareness of the benefits that MSFW’s ring to America

 Continue research examining policy, social and physical environment

 Continue research on variables such as patient preferences, site of medical care and

cultural views on attaining healthcare independent of financial limitations

 Develop better strategies for tackling health disparities

 Increase provider awareness and cultural sensitivity

 Increase farmowners awareness to what time of services they are qualified to use

 Increase outreach efforts with mobile units, promotores and clinical health navigators

 Increase availability of multilingual text documents incorporating the use of pictures to Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

address the illiterate populations

 Increase health education efforts using multimedia and bilingual, bicultural instructors

 Increase insurance coverage to undeserved populations who are doing jobs that most

Americans will not do under the same type of circumstances

 Increase accountability of farmowners, policymakers and healthcare teams

CONCLUSION

Migrant and Seasonal Farm Workers are an indispensable asset that the United States can no longer neglect. It is our duty to help them overcome the hurdles they must overcome every day just to live; as well it is our duty that we must push forward so they can have better health outcomes. There is plenty of good literature to be able to understand better the issues about

Migrant Health problems. There are also many good resources nationwide in regards to videos and educational material that can be used to learn more about their situation and also that will allow them to learn more of how to effectively navigate out difficult health care system and health care in general. Lets make sure that information is disseminated.

While we conduct more research and struggle to raise awareness, MSFW’s and their families continue to suffer. There are already some good signs though. Some public programs exist already to provide relief in emergency situations. Some exist to assist with prenatal care and delivery. Some exist to make immunizations available to all. There are some positive efforts in progress and in action but the inequities far outweigh the efforts. According to Maslow’s Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos hierarchy of needs the basic needs of a human are physiologic, safety and security, love and belongingness, esteem, and self actualization. We must fight to make sure such a disadvantaged population of our society can have a change to reach this self-actualization. As MSFW’s population rates continue to increase, our awareness and effect to help must grow with them.

Their good health and the health of their children will have a significant impact on the socioeconomic future of all Americans. Let’s make sure that we do our part.

REFERENCES

JOURNALS

Busssel, R. et al. Understanding the Immigrant Experience in Oregon: Research, Analysis, and

Recommendations from University of Oregon Scholars.

http://www.uoregon.edu/~lerc/pdfs/immigrationenglish.pdf

Derose K.P, Escarce J.J., Lurie N. (2007) Immigrants and Health Care: Sources of

Vulnerability. Health Affairs 26: 1258-1268.

http://content.healthaffairs.org/cgi/content/abstract/26/5/1258

Franzini L., Fernandez-Esquer M.E., (2004). Socioeconomic, cultural, and personal influences

on health outcomes in low income Mexican-origin individuals in Texas. Social Science &

Medicine 59:1629-1646. http://www.ncbi.nlm.nih.gov/pubmed/15279921 Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

Holmes S.M. (2006). An ethnographic study of the social context of migrant health in the

United States. PLoS Medicine 3, (10):e448. http://medicine.plosjournals.org/perlserv/?

request=get-document&doi=10.1371/journal.pmed.0030448&ct=1

The Kaiser Family Foundation, (2008). Kaiser Commission on Key Facts: Summary – Five

Basic Facts on Immigrants and their Health Care. http://www.kff.org/medicaid/upload/7761.pdf

Larsen A. Environmental / Occupational Safety and Health. Migrant Health Issues.

Monographs No2. Washington, DC: National Center for Farmworker Health

http://www.ncfh.org/docs/02%20-%20environment.pdf

Livingston G., Minushkin S., Cohn D.V. (2008). Hispanics and Health Care in the United

States: Access, Information and Knowledge. Washington DC: Pew Hispanic Center and Robert

Wood Johnson Foundation; p4-9. http://pewhispanic.org/files/reports/91.pdf

Meredith K., (2007). Immigrants in the U.S. Health Care System: Five Myths That Misinform

the American Public. Center for American Progress.

http://www.americanprogress.org/issues/2007/06/pdf/immigrant_health_report.pdf

Orozco M, Castillo N, (2008). Latino migrants: A profile on remittances, finances, and health.

Washington, DC: Inter-American Dialogue.

http://www.thedialogue.org/PublicationFiles/Remittance%20senders%20profile%20generic.pdf

Wallace S.P. et al (2007). Migration, Health & Work: Facts Behind the Myths. Mexico:

Regents of the University of California and Mexican Secretariat of Health. [Chapter 3] Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

http://hia.berkeley.edu/documents/mig_hlth_wk.pdf

Warnecke R.B. et al (2008). Approaching Health Disparities From a Population Perspective:

The National Institutes of Health Centers for Population Health and Health Disparities.

American Journal of Public Health. September 2008, Vol 98, No 9 1608-1615

http://www.ajph.org/cgi/content/abstract/98/9/1608

Weathers A.C. et al (2008). The Effect of Parental Immigration Authorization on Health

Insurance Coverage for Migrant Latino Children. Journal of Immigrant & Minority Health

10(3): 247-254. http://www.springerlink.com/content/0lm1856072753p75/fulltext.pdf

Zuniga et al (2006). Mexican and Central American Immigrants in the United States: Health

Care Access. Mexico: Regents of the University of California and Mexican Secretariat of

Health. http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

VIDEOS

Promotoras Exchange Video. Health Initiatives of the Americas. University of California

Berkeley. http://hia.berkeley.edu/promotorasvideos.shtml

California’s Harvest of Shame. United Farm Workers. http://www.ufw.org/_board.php? Shannon Paris Access to Health Care for MSFW’s and their Families in OR & WA Oscar Ramos

mode=view&b_code=res_multi&b_no=4663&page=1&field=&key=&n=126

MiVIA (video). Healthcare 360: Monitoring American Access

https://www.mivia.org/PressMain.aspx