Oct 2018

How Should Physicians Help Patients Who Are Ill Because They Work in Agriculture?

Nicole Civita, JD, LLM
AMA J Ethics. 2018;20(10):E932-940. doi: 10.1001/amajethics.2018.932.

Abstract

Occupational health issues are not just common for farmworkers; they are practically unavoidable. Farmworkers who seek treatment for work-related injury or illness are often unable to meaningfully reduce their exposure to risk factors without further jeopardizing their already fragile well-being and tenuous livelihoods. This case commentary addresses why and how physicians presented with patients who are ill because they work in agriculture should adjust their clinical practices to better meet the unique challenges faced by this patient population. In recognition of physicians’ ethical duty to participate in activities to protect and promote the health of the public, this commentary also recommends specific actions that medical professionals can take to support systemic change that would improve farmworker health and well-being.

Case

Dr A works in a health clinic that serves several surrounding agricultural counties. His first patient of the day is Mr L who presents with nausea, abdominal pain, and diarrhea. According to the patient, he had been feeling fine until the past 24 hours. At first, he thought something he ate had made him feel ill, but neither his wife nor his 3 children had any of these symptoms.

Mr L explained that he recently learned that a friend with whom he works was experiencing similar symptoms. Even though Mr L felt a little better this morning—well enough to go to work—his wife was adamant that he see a physician because “he has never been sick a day in his life.”

Further discussion revealed that Mr L worked on one of the local farms where, during the past couple of days, pesticides and herbicides were extensively sprayed in the surrounding fields. Mr L said, “I started to notice a chemical smell coming from the orchards west of the strawberry fields where I was working.”

Dr A stated, “While I can’t say for sure, I strongly suspect that your belly pain and other symptoms are a result of agricultural pesticide and herbicide exposure. I recommend that you not return to work until the spraying is complete.”

“I have to work, Doc. My family depends on me. Besides, we’re always spraying something.”

Dr A is not sure how to respond to Mr L. Moreover, Dr A is concerned about the health of other farmworkers in the area who are also being injured by agricultural pesticide and herbicide exposure.

Commentary

Farmworkers who become ill as a result of occupational conditions cannot reduce risk factors without exposing themselves and their families to greater, often more immediate perils. Treating marginalized patients made ill by the conditions of their essential but hazardous work raises ethical issues and requires active engagement. To serve such patients, physicians should (1) appreciate the circumstances and vulnerabilities of farmworkers, (2) consider the feasibility and ramifications of treatment, (3) seek to enhance access to care and reduce barriers to treatment through collaboration, and (4) report dangerous conditions and advocate for systemic reform.

Circumstances and Unique Vulnerabilities of Farmworkers

Inherent hazards of farmwork. A farmworker’s body is his primary vocational asset. Paradoxically, a farmworker’s vocation is the primary threat to his body. Good days in the field require swift, exertive, and repetitive motion with sharp implements, putting farmworkers at high risk for degenerative musculoskeletal injuries.1 On bad days, one-third to one-half of farmworkers are exposed to pesticides and other agrichemicals. At best, toxic encounters can cause skin and eye irritation, headaches, and flulike symptoms, such as those Mr L presents with. At worst, they are implicated in disproportionately high rates of heart disease and certain cancers.2

Farmworkers are exposed to the elements for long hours with few breaks. Most retire to dilapidated, crowded housing which might lack bathing or laundry facilities. Harsh working and substandard living conditions lead to acute illnesses and infections and undermine recovery.3 Ultimately, agricultural workers face an occupational fatality rate roughly 5 times that of other workers.4 In short, farmworker health is compromised to produce affordable vegetables, fruits, nuts, and berries—the very foods recommended for good health in the general population.

Structural violence—systematic ways that prevailing political, economic, and social forces damage individuals and groups5—drives farmworkers to migrate for work and continues in the United States. A cascade of clinically relevant stressors and harms flows from free trade, neoliberal globalization, political instability, violent turmoil, social inequities, racism, and bias. Separation from family, social isolation, and, for some, the peril of illegal border crossings and constant threat of deportation decrease workers’ ability to cope.6,7 Physiological consequences of stress, working poverty, and malnutrition8 exacerbate illness and stymie healing.

Farmworkers’ deep dependence on their jobs. When Mr L told Dr A, “I have to work,” he was not exaggerating. Mr L’s family probably lives paycheck to paycheck, so skipping shifts can be ruinous. Difficult, hazardous work is usually well compensated, but farm work is notoriously low paid. Median wages hover around $11.41 per hour, and the median annual income from farming is $23,730.9 In addition, farmworker housing and transportation are often employer provided and cut off as soon as the worker ceases to be a productive asset. Stopping work can lead to sudden homelessness. For migrants, it can also mean isolation from one’s community in displacement—the people with whom they travel, live, and labor.

Migration and immigration status also contribute to farmworkers’ insecurity. Undocumented workers often owe steep debts to coyotes and labor contractors who finagle border crossings and job placements. Inability to pay ruthless criminals could have violent repercussions.3 Farmworkers with H-2A visas are authorized to work in the United States only as long as they remain employed by their sponsor. Changing farms or industries means losing legal status and risking immediate return.10 Because most farmworkers cannot take time off without facing termination, eviction, deeper poverty, separation from social supports, violence, or deportation,11 Dr A should make further inquiries to assess the ramifications of advising his patient to avoid work.

Making Viable Treatment Recommendations

When treating farmworkers, context is critical. It is essential to gather information—about patient history, living conditions, workplace characteristics, socioeconomic factors and other structural forces such as policies and regulations—that bears upon the feasibility and consequences of treatment for members of this marginalized population.

Physicians in rural agricultural areas should get to know local agriculture: the types of crops typically grown, major agricultural employers and their reputations, production practices and agrichemicals commonly used, and the range of manual and machine-assisted work performed. They should talk to county agricultural extension agents, attend gatherings of farmers, and host special farmworker care clinics (discussed below) to build relationships. Finally, they should leverage employers’ desire for a stable, vigorous workforce to improve working and living conditions, treatment possibilities, and health outcomes for farmworker patients.

When work restrictions are medically necessary, physicians should articulate specific medically necessary restrictions in lieu of generic “light duty” dictates, which often result in mandatory, unpaid, and unaffordable time off. Sometimes, all available work is somewhat strenuous. But, more likely, managers erroneously believe that farmworkers are unfit for all but the most menial tasks. Racialized hierarchies, stereotypes about farmworkers—especially migrants—and the indignities of poverty segregate owner-operators (“locals” employed in managerial or administrative positions) from seasonal or temporary workers and also block most nonmanual work opportunities for farmworkers.7 Understanding the type of work done on area farms would enable Dr A to make tailored recommendations about alternative work, reasonable accommodations, and necessary safety measures, instead of directing his patient to stop work entirely. (Workers usually don’t have a comprehensive picture of the farm’s operations and may not be positioned to make suggestions.) Suitable alternative manual tasks may not always be light but can be less taxing on parts of the body in particular need of recuperation or may put remedial distance between the worker and certain toxic agrichemicals. Moreover, specific recommendations from a physician can help circumvent the structurally racist workplace dynamics that prevent migrant and seasonal workers from being granted less hazardous placements.

Additionally, clinicians should provide migrant workers with easy-to-read and understand information in their native language about how to reduce exposure through use of protective equipment, more frequent hand washing and showering, and laundering of clothes.12-14 Never assume that basic measures are feasible. Instead, ask about the patient’s access to (and training on) safety equipment and access to washing facilities and clean clothes.

Dr A should question Mr L further about his work and hygiene habits. “Did you inform your supervisor about the chemical smell? Do you think the pesticides were being sprayed by your employer or on nearby farm? Is safety equipment provided? How soon after your shift can you shower, change, and wash your clothes?” He should also make inquiries designed to reveal the social and power dynamics on the farm. “Do you know of any indoor or nonmanual positions on the farm? Do such jobs ever go to noncitizen employees or to people of color? If I restricted your work, whom would you tell? How do you expect they would react? Have any other employees needed a work restriction? What happened when they made their needs known?” This type of inquiry could help Dr A develop nuanced recommendations, counsel Mr L about advocating for his health needs, and gather pertinent information to disclose to authorities (discussed below).

Making Care for Farmworkers More Accessible and Comprehensive

When serving patients who are ill because they work in agriculture, health care professionals should adjust their clinical practice to reduce barriers to care, benefits, and support services that improve health outcomes. In this case, the patient has actually made his way to the doctor’s office, but all too often farmworkers are unable to clear the time and transportation hurdles to do so (at all or more than once). Language barriers, situational discomfort, and below-average health literacy might add layers of difficulty.12 Thus, it is useful for clinicians to build a network and provide referrals to physicians, pharmacies, counselors, translators, and other health care workers who also provide culturally competent care.

Holding on-farm clinics enables screening, early identification of conditions, and follow-up, which could drive better outcomes. It also gives physicians greater insight into workplace conditions and dynamics. Onsite services should be provided in dignified, private settings that promote patient comfort and candor. During a “farm call,” with the patient’s consent, hazard reduction, rotation of duties, and opportunities for true light duty placement after injury can be discussed directly with the owner-operator or supervisor. Physicians who are concerned about exposing themselves to toxins on farms should confer with the farm owner(s) to set clinic hours during times between applications of agrichemicals. If site visits are not feasible, permitted, or are deemed too risky, health care practitioners can schedule special clinic hours when workers are less likely to be on the clock and more able to travel into town.

Health care practitioners in predominately agricultural areas should also identify and coordinate with complementary health care workers, such as legal aid attorneys, social service agents, nutrition assistance outreach programs, and translators able to communicate in relevant languages (not always Spanish) since enhancing farmworker-patient access to a range of public, free, or low-cost social services promotes well-being. Social services could help reduce farmworkers’ dependence on hazardous jobs by improving access to tangible resources (eg, sanitary facilities, toiletries, food aid, and donated clothing). Legal assistance can help farmworkers claim unpaid wages, address unsafe working conditions, facilitate access to safety equipment, and protect farmworkers from retaliation.

If workers’ compensation coverage is available,7 clinicians should consider the ramifications of their notes, diagnoses, and treatment recommendations, all of which influence access to essential benefits. Understanding how employers, insurers, and the legal system are likely to respond to the restrictions prescribed can help to keep a discrete illness (eg, acute pesticide exposure) from ballooning into an intractable vulnerability (eg, homelessness, hunger, and loss of income while sick). Because benefits could be denied if physicians chart suspicions of malingering, physicians should check their own biases and be attuned to the influence of language and cultural differences, confusion, and fear on their assessment of the patient’s credibility.15,16 Farmworkers have little incentive to fake illness or injury. They perform noble, necessary, and notoriously dangerous work upon which we all rely, and they should be given the benefit of the doubt.

Alert Authorities and Support Systemic Change

Because opportunities for effective treatment of individual farmworker-patients are sharply constrained by economic realities, physicians should not limit their response to patient interactions. In furtherance of their ethical duty to participate in activities to protect and promote public health, physicians should actively support systemic change for improved farmworker health and well-being.17 Existing farmworker protections and environmental laws fall short, leaving ample room for improvement. Indeed, some wage laws tie worker pay to productivity, incentivizing workers to jeopardize their own health.18 Even when appropriate laws are in place, enforcement capacity is terribly limited.19

When unsafe conditions, including pesticide toxicity, are suspected, physicians must alert the relevant regulatory authorities for investigation. Because most states mandate pesticide incident reporting,20 the Health Insurance Portability and Accountability Act (HIPAA) limitations on releasing personal health information (PHI) do not bar disclosure of PHI for public health activities.21 The Migrant Clinicians Network’s pesticide reporting map can be used to identify local reporting requirements.20 In this case, Dr A believes that his patient and at least one of his coworkers have been exposed to pesticides in unsafe ways. He has also been told that the farm is “always spraying something.” Based on this information, Dr A has an ethical and (in most places) a legal obligation to alert public health officials.

In addition to complying with mandatory reporting requirements, medical professionals are well positioned to illuminate unlawful conduct, regulatory violations, and systemic barriers to farmworker well-being. Physicians, individually or through professional associations, should support structural reform by engaging with local public health agencies and testifying about occupational hazards, resulting injuries, and public costs. In so doing, they can shed light on problematic access to health care and expose flaws in the workers’ compensation system. Physicians who relate well to local agricultural leaders might be able to marshal support for policies and funds that create a social and economic safety net for farmworkers. Such initiatives are ethically important because they improve worker health and well-being and support the agriculture sector, enabling production of healthy food for all.

Summary

Farmworkers who experience toxicity from exposure to agrichemicals (among other occupational injuries and illnesses) struggle to heal because they have little ability to avoid workplace hazards and cannot take time off without becoming financially and socially vulnerable. Accordingly, in a clinical context, physicians must explore the feasibility and ramifications of treatment recommendations with patients before telling them to stop work, change duties, or even undertake basic hygienic practices. Because many farmworkers are not native English speakers, having a translator available and using easy-to-understand visual materials are essential for effective communication. Physicians should also remain cognizant of how third parties (eg, employers, insurers, and the legal system) are likely to respond to their notes, diagnoses, and prescriptions. It is critical for physicians to check their own assumptions and biases before concluding that a farmworker patient, who might be frightened, confused, or traumatized, is untrustworthy or malingering.

Moreover, because the health of farmworkers is more substantially degraded by structural forces than by individual experiences and behaviors, physicians seeking to treat causes rather than symptoms should also attend to the systems in which farmworkers live, work, and struggle. To better serve farmworker patients, physicians—especially those working in rural agricultural areas—should learn about the nature and dynamics of the agricultural sector in their region so that they can articulate feasible treatment recommendations and work restrictions. By building relationships with agricultural leaders and employers, physicians might be able to shine a light on practices that harm farmworkers’ health and help identify alternatives that could both reduce the incidence and severity of harms and provide sick or injured workers with meaningful opportunities to recuperate. Physicians could also consider modifying the times, places, and manner in which they deliver health care services to reduce barriers to access and coordinating with complementary social and legal services workers to increase the range of support that an ill or injured farmworker can access.

In addition to these collaborative approaches, physicians should take seriously their legal duties to promptly report unsafe working conditions to the appropriate authorities. Relatedly, physicians should make good on their ethical duties to enhance public health by engaging in or supporting reform campaigns aimed at improving farmworker health and well-being. Making extra efforts to appreciate the contexts in which farmworkers toil, are injured, and struggle to heal will enable physicians to provide high-quality care to a group of people who are often overlooked.

References

  1. Davis KG, Kotowski SE. Understanding the ergonomic risk for musculoskeletal disorders in the United States agricultural sector. Am J Ind Med. 2007;50(7):501-511.
  2. Blair A, Freeman LB. Epidemiologic studies in agricultural populations: observations and future directions. J Agromedicine. 2009;14(2):125-131.
  3. Rothenberg D. With These Hands: The Hidden World of Migrant Farmworkers Today. Berkeley, CA: University of California Press; 2000.

  4. Frank AL, McKnight R, Kirkhorn SR, Gunderson P. Issues of agricultural safety and health. Annu Rev Public Health. 2004;25(1):225-245.
  5. Farmer P. An anthropology of structural violence. Curr Anthropol. 2004;45(3):305-325.
  6. Massey DS, Durand J, Malone NJ. Beyond Smoke and Mirrors: Mexican Immigration in an Era of Economic Integration. New York, NY: Russell Sage Foundation; 2003.

  7. Holmes S. Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States. Berkeley, CA: University of California Press; 2013.

  8. Borre K, Ertle L, Graff M. Working to eat: vulnerability, food insecurity, and obesity among migrant and seasonal farmworker families. Am J Ind Med. 2010;53(4):443-462.
  9. Bureau of Labor Statistics, US Department of Labor. Agricultural workers. Occupational Outlook Handbook. https://www.bls.gov/ooh/farming-fishing-and-forestry/agricultural-workers.htm. Updated April 13, 2018. Accessed July 19, 2018.

  10. US Department of Labor. Work authorization for non-US citizens: temporary agricultural workers (H-2A visas). https:/webapps.dol.gov/elaws/elg/taw.htm. Accessed April 27, 2018. 

  11. Snipes SA, Cooper SP, Shipp EM. “The only thing I wish I could change is that they treat us like people and not like animals”: injury and discrimination among Latino farmworkers. J Agromedicine. 2017;22(1):36-46.
  12. Pysklywec M, McLaughlin J, Tew M, Haines T. Doctors within borders: meeting the health care needs of migrant farm workers in Canada. CMAJ. 2011;183(9):1039-1043.
  13. Migrant Clinicians Network. Resources. https://www.migrantclinician.org/tools-and-resources/resources_intro.html. Accessed April 27, 2018.

  14. Migrant Clinicians Network. Pesticide comic books. https://www.migrantclinician.org/issues/occupational-health/pesticides/pesticide-comic-books.html. Accessed April 27, 2018.

  15. Farmworker Justice. State workers’ compensation coverage for agricultural workers. https://www.farmworkerjustice.org/sites/default/files/documents/6.3.a.1State_Workers_Comp_Information_for_Health_Centers_11-09.pdf. Published 2009. Accessed April 27, 2018.

  16. American Medical Association. Opinion 8.5 Disparities in health care. Code of Medical Ethics. https://www.ama-assn.org/delivering-care/disparities-health-care. Accessed April 27, 2018.

  17. American Medical Association. Opinion 8.11 Health promotion and preventative care. Code of Medical Ethics. https://www.ama-assn.org/delivering-care/health-promotion-and-preventive-care. Accessed April 27, 2018.

  18. Earle-Richardson G, Jenkins PL, Slingerland DT, Mason C, Miles M, May JJ. Occupational injury and illness among migrant and seasonal farmworkers in New York State and Pennsylvania, 1997-1999: pilot study of a new surveillance method. Am J Ind Med. 2003;44(1):37-45.
  19. Bon Appétit Management Company Foundation; United Farm Workers. Inventory of farmworker issues and protections in the United States. http://www.bamco.com/content/uploads/2016/08/farmworkerinventory_0428_2011_updated2016.pdf. Published March 2011. Accessed April 23, 2018.

  20. Migrant Clinicians Network. Pesticide reporting and workers’ compensation in agriculture—interactive map. https://www.migrantclinician.org/issues/occupational-health/pesticides/reporting-illnesses. Accessed on April 27, 2018.

  21. 45 CFR §164.512(b) (2018).

Editor's Note

The case to which this commentary is a response was developed by the editorial staff. 

Citation

AMA J Ethics. 2018;20(10):E932-940.

DOI

10.1001/amajethics.2018.932.

Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.