NurseWeek: Suffering in Silence

Suffering in silence
California’s agricultural industry booms, but health care of low-paid farm workers remains neglected

By Nancy Devine
January 29, 2001
Photo: Bill Gillette

The same farmworkers who help pull in a massive $26.7 billion worth of crops sold annually in California are at risk for chronic diseases caused by poor nutrition, and have limited access to treat those illnesses.


	You've read the article. Now tell us what you think. Related sites Read the report California Endowment California Employment Development Department California Institute for Rural Studies Health survey findings Today, 61 years after John Steinbeck’s The Grapes of Wrath riveted national attention on the poverty of farm workers, the California Agricultural Worker Health Survey documents just how much more remains to be done to help workers access basic health services. The survey research included a 71-page questionnaire and physical exam administered to 971 workers, and was funded by The California Endowment, the state’s largest health care foundation. Selected summarized findings: Workers are predominantly young married Mexican men with little formal education, earning between $7,500 and $9,999 annually. One in five males had at least two of three risk factors for chronic disease: high serum cholesterol, high blood pressure or obesity. About 81 percent of males and 76 percent of females had unhealthful weight, as measured by body mass index. Males and females showed evidence they are likely to suffer from iron deficiency anemia more than normal for U.S. adults. More than one-third of males had at least one decayed tooth, and nearly four out of 10 females had at least one broken or missing tooth. Nearly 70 percent lacked any form of health insurance. About 32 percent of males said they had never been to a doctor or clinic, while 37 percent of females had had a medical visit in the last five months. Two-thirds of workers reported never having had an eye care visit. ~ Nancy Devine

Ann Souter, RN, helps farmworkers find sorely needed medical attention despite serious obstacles. "I saw one young man who had cut his foot on glass and was so afraid of being deported if he went to a doctor for help that he went home, drank half a bottle of whiskey, and sewed up his foot with sewing needles," said Souter, who works for the Yolo County Public Health Department in California. "If a person won’t go to a health clinic with a huge gaping hole in their foot, that’s a problem telling us somewhere our system has failed."

Immigrant farmworkers like that young man help pull in a massive $26.7 billion worth of crops sold annually in California. But those same workers are likely to be at risk for chronic diseases caused by poor nutrition, and have limited access to health care to treat those illnesses, says the California Agricultural Worker Health Survey "Suffering in Silence: A Report on the Health of California’s Agricultural Workers." The survey set out to pinpoint the size and origin of the health gap among the workers harvesting the nation’s largest cornucopia of fruits and vegetables.

This landmark survey interviewed and examined workers in seven farming communities to accurately assess their health. The sites represented the state’s six agricultural regions: Arbuckle (Sacramento Valley), Calistoga (North Coast), Cutler and Firebaugh (San Joaquin Valley, where half the state’s agricultural workers are employed), Gonzales (Central Coast), Vista (South Coast), and Mecca (Desert). Conducted by the California Institute for Rural Studies, the survey revealed an alarmingly high risk for heart disease, stroke, hypertension, diabetes and obesity among agricultural workers, including young men who should be in peak physical condition.

These workers are the muscle behind California’s billion-dollar agricultural industry, a silent labor force estimated at 800,000 to 900,000 hired workers, according to immigration studies for the state’s Employment Development Department. Most U.S. citizens won’t work for agriculture’s low wages nor accept the dangerous conditions, which are second only to the construction industry, according to the National Safety Council.

"Those who harvest California’s bountiful fruits and vegetables are still the poorest people in the state," said Don Villarejo, Ph.D., California Agricultural Worker Health Survey project principal investigator, and founder and former director of the California Institute for Rural Studies. "As CDC data has shown, the single most important predictor of health is socioeconomic status, and the lower the status, the lower their level of diet. Unhealthful diet is one of the major factors in the chronic health outcomes we reported."

Industry growth
Today, more than 50 percent of all the nation’s major vegetable production and 40 percent of major fruit production comes from California. The industry has doubled because Americans are eating more produce than ever, fueled by nutritional education and the USDA’s recommendation advocating five servings of fruit and vegetables a day. The result is increased recruitment of migrant workers from Mexico and elsewhere. Along with difficult conditions and unhealthful diet, tax-paying farmworkers suffer from limited access to health services.

"I examined older women who had had babies at home but never had a pelvic exam," said Rhoda Schaepe, NP, who works at Vista Community Clinic in Vista, one of the health survey’s seven sites. "When I explained why we do them their eyes got big; it was brand-new that this was something they should do. But I spoke Spanish and took time explaining, and they were so grateful to learn that some hugged me."

Nurses for rural clinics or mobile services play a pivotal role helping teach farmworkers about health and hygiene. Nurses also are learning more about cultural differences, which helps them better understand workers’ concerns.

"I notice nurses are much more flexible and willing to take into account the perspective of the client and incorporate that into their treatment of our transnational migrants," said Bonnie Bade, Ph.D., a health survey co-investigator and associate professor of medical anthropology at California State University, San Marcos. "It’s important they understand practices in rural Mexico are very different from here."

The survey states that because most agricultural workers are foreign-born, do not speak or read English, live in poverty and are undocumented, no other group of workers in America faces greater barriers in accessing basic health services.

"Most of these people are ‘illegals,’ so they’re not eligible for Medi-Cal or state services," said Souter, who worked as a survey site coordinator for three of the seven sites. "But they’re wage earners who told us they’d be willing to pay a percentage for services. Nobody’s asking for a handout, just something affordable. They put the food on our tables, and yet they’re taking all the risks: exposure to pesticides, bacteria and a high percentage of injury," Souter said. "It’s unreal; in Mecca, it’s 127 degrees out in the fields. We need to do more for them."

Language is a major barrier to access. About 18 percent of those who said they had visited a doctor or clinic visit went to Mexico for that care. Fear of deportation also is a barrier. Money is a barrier because employers are not required to provide health insurance, and the few that do also require premiums or co-payments that workers can’t afford. Money clearly is a barrier to good nutrition as well. "These workers are essentially victims of inexpensive high-fat fast-food," Souter said. "Too many fried foods."

Add culture, transportation, education and inconvenient clinic hours, and that’s a lot of barriers to health care. An array of cultural barriers include traditions of self-medication and the purchase of medicine and injections in Mexican pharmacies without a prescription. "Low literacy cultures prefer an oral tradition with everybody, so any forms to deal with also create another barrier," Villarejo said.

The health survey Villarejo led has received the attention of state legislators, and a task force has been created to propose solutions to the state’s farmworker health crisis. In the meantime, nurses may be the best-positioned health care professionals for providing assistance.

"My advice to nurses who see these workers is speak the language, learn about the culture, respect workers’ privacy and don’t overwhelm them with terminology," Schaepe said. "They need immunizations, help with skin infections, education and someone there for them. The people I saw were so pleased we had taken time to help them. It was very special. Offering health care is such a tremendous thing we can do for these people."