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Photograph by Rory McNamara

To Your Health: They tend to the vines, but do they tend to their health?

Silent Suffering

North Bay farm workers face a healthcare crisis

By Joy Lanzendorfer

Efran Castillo was in pain. For some days, the vineyard worker had been hobbling around. He had stepped in a hole, fallen, and hurt his ankle. Since he spoke no English, had no healthcare insurance, and didn't know how to get help, he simply tried to live with the pain.

His supervisor, noticing his problem, told Castillo that his injury was covered by workers' compensation and took him to the nearest emergency room. There, no one spoke Spanish, and even with the supervisor translating for him, Castillo found the hospital intimidating and confusing. Nearly illiterate, he had trouble filling out the required forms. After waiting hours and being shuffled from room to room, his ankle, which was broken, was put in a cast.

Castillo was assigned no doctor, and follow-up care was not clearly explained to him; when it came time for the cast to be removed, he naturally went back to the emergency room. Since federal law dictates that hospitals cannot turn away people seeking care at an emergency room, the hospital had no choice but to devote emergency resources to a nonemergency situation.

Farm workers tend to have more health problems than most other groups of workers in Sonoma and Napa counties but less access to care. As a result, they often misuse the already overtaxed emergency departments or let problems get to the breaking point before finally seeking help. And because the issue has not been tracked, no one really knows how big the problem is. One thing is clear, though: as the number of migrant and farm workers increases and the cost of health insurance continues to go up, this issue will weigh more and more heavily on the North Bay's sagging healthcare system.

Uninsured, Uniformed

The exact number of both regular and migrant farm workers in Sonoma and Napa counties is unknown. The 2000 census showed that Latinos made up 23.7 percent and 17.3 percent of Napa and Sonoma counties' population, respectively. And few of the farm workers have health insurance, though again the numbers are sketchy. In Sonoma County, 60,000 people are estimated to be uninsured, but experts have called that number low, and no one knows how many are farm workers. Napa's Queen of the Valley Hospital estimated that 64 percent of Latinos in Napa County are uninsured.

"No one has hard numbers on how many uninsured farm workers are in our area," says Jeff Meckler, M.D., medical director of Alliance Medical Center in Healdsburg, which primarily serves the Hispanic population. "It depends on what type of worker you're talking about. The undocumented workers rarely have insurance. With the documented workers, it depends on whether or not their employers offer insurance."

But whether insured or not, Hispanic workers often have health problems related to their lifestyles. Farm workers tend to eat a lot of fast food, loaded with fat and sugar, which puts them at a greater risk of obesity and high cholesterol and in turn ups their chances of getting chronic conditions such as diabetes and high blood pressure. Though immediate injuries such as Efran Castillo's broken ankle are covered by workers' comp, other kinds of work problems can be ignored, such as ongoing back pain or foot injuries.

"We primarily see a lot of untreated chronic conditions, especially diabetes, high blood pressure, and hypertension," says Beatrice Bostick, head of Community Health Clinic Ole, the main source of healthcare for Hispanic workers in Napa County. "Chronic illnesses are troubling to treat, because even when we diagnose a problem, it is difficult to get the workers to come back for follow-up care."

The effect of pesticides on farm workers is also becoming a concern. A study published last year in the American Journal of Industrial Medicine showed that Hispanic farm workers in California have much higher incidents of leukemia, as well as brain, stomach, and skin cancers. The study did not, however, establish a clear link between the cancer rates and pesticide exposure.

Local doctors haven't seen as many cases of cancer as the study suggests they would. Some speculate that this may be because pesticides used in vineyards are somewhat gentler than those used on other kinds of crops; others believe it may be because very ill workers tend to return to Mexico for treatment.

But some doctors are seeing other disturbing trends that may be linked to pesticides. Meckler, for example, has seen several cases of birth defects in the last five years. One baby was born without eyes and several others with abdominal wall closures.

"I have no idea if the birth defects we've seen have anything to do with pesticides or not," he says. "It just seems like we've seen more than you would expect. It would be good if there was some reporting system to collect hard evidence on whether this is at all linked to pesticide exposure."

Because migrant workers often leave family behind in Mexico when they come to the United States for economic reasons, they are often socially and emotionally isolated, which leads to high incidents of depression and other mental illnesses, some experts believe. And though there are a considerable number of programs directed at children of farm workers, a lot more could be done to ensure the children's care.

Doctor, Doctor

With a lack of numbers on how few North Bay farm workers are getting the care they need, the problem may be worse than many realize. A study of 971 California farm workers (including those in the North Bay) by the California Institute of Rural Studies revealed that more than a third of the men had never been to a doctor in their lives. Even fewer people had dental and eye care. More than half the men and two-fifths of the women had never been to a dentist, and two-thirds of both sexes had never been to an eye doctor. Not surprisingly, nearly 70 percent of those surveyed lacked any form of health insurance, and only 7 percent were covered by a government-funded program.

But poor healthcare access for farm workers is more complicated than the fact that many employers don't offer insurance, though that is part of the problem. In fact, some vineyards and farms do offer health insurance. Alliance Medical, for example, estimates that roughly one-quarter of its Hispanic patients are insured through their employers. Queen of the Valley Hospital estimated that nearly one-third of Napa County Latino residents have insurance.

"Some vineyard owners do provide insurance for their workers," says Andy Demsky, spokesperson for the Napa Valley Vintner's Association. "There is even seasonal coverage for temporary workers. It just depends on the vineyard."

But even when employers do offer insurance, many workers can't afford the co-payments. Because migrant workers can earn less than $10,000 a year, co-payments must compete with other more immediate needs such as food and housing. Though nearly 17 percent of those surveyed in the CIRS study said their employers offered health insurance, one-third of that amount didn't participate in the plan because they couldn't afford the payments.

When employees don't have healthcare insurance, their options are greatly reduced. Legal aliens can apply for government programs such as Medi-Cal, which will cover some of their needs. Clinics like Community Health Clinic Ole and Alliance Medical will work with patients to develop a sliding-scale fee based on their income and whatever insurance they have.

As in Castillo's case, the misuse of emergency rooms is also a common path for the poor. Since hospitals must offer care regardless of the patient's ability to pay, many uninsured people use ERs as their primary care providers. Because of this and other factors, the majority of emergency rooms in the nation are losing money and have no way to recoup costs. And misuse adds to overcrowding in the emergency room, so that severely ill or dying patients are often turned away because the beds and resources are already in use.

Greek to Me

When it comes to dealing with being uninsured, farm workers are no worse off than other low-income workers who can't afford healthcare. However, Mexican workers have extra obstacles that other working poor don't have, according to Rick Mines, Ph.D., one of the researchers who worked on the CIRS study.

"The farm workers are similar to other working poor in terms of healthcare access, except they have additional cultural barriers," he says. "These barriers are a huge problem. We found that because they don't have these barriers, the working poor can utilize the healthcare system much better than the farm workers can."

All such barriers are secondary to illegal aliens, who often fear that seeking healthcare will put them at risk for deportation. As a result, many will not get help unless they are very sick. But beyond this, the most obvious cultural barrier is language.

In Sonoma and Napa counties, many healthcare providers have bilingual people on staff, but they are usually in the minority. And even if there is a large bilingual staff, few specialists and doctors are bilingual. Without someone there to translate, farm workers have trouble explaining symptoms, may not understand prevention and care instructions, and can't ask for clarification if they are confused. Put all this on top of feeling sick--sick enough to seek care when you typically avoid doing so--and it's easy to see why language would be a huge issue for the worker to contend with. And language barriers are one of the reasons workers don't understand what healthcare resources are available to them in the first place.

Transportation is also an issue, especially when cash-strapped workers can't afford to take much time off work, according to Kathy Ficco, executive director of the Medical Access Program at St. Joseph Health System, Greater Sonoma County.

"We have one woman who needed to go from Roseland to Southwest Community Health Center on Lombardi Court in Santa Rosa, a 10-minute drive for you and me," she says. "On the bus, it was an hour and a half to get to the clinic. In her case, she usually has three sick children with her. It's very difficult for them to travel without a car."

But perhaps more than anything else, it is the cultural strangeness of our healthcare system that keeps many workers from seeking care. To be unable to get to a healthcare provider and then explain yourself once there are both definite obstacles, but that's nothing compared to not knowing where to go and how the system works to begin with.

In Efran Castillo's case, uncertainty of how the local healthcare system works kept him from getting help for his ankle and made the experience confusing and intimidating when he finally did. The California Institute of Rural Studies found that most farm workers prefer Mexican healthcare, which is quite different from U.S. healthcare. Though not as accurate and careful, Mexican healthcare means less bureaucracy and waiting, fewer laboratory tests, quicker diagnosis, and immediate issuance of medicine, all by someone who, of course, speaks Spanish and shares the same cultural background as the patient.

Maria Matsen, who worked with migrant and farm workers in Napa County for 12 years and is a member of the Latina Advisory Board, feels that cultural sensitivity is the first step to reaching the throngs of unknown health problems among the farm workers.

"Yes, we have Health Clinic Ole and some other healthcare resources in Napa County, but we could do a lot better," she says. "Cultural sensitivity is the key to understanding how this group of people works. We can't expect them to change to our way of doing things. We would be better off teaching them how to incorporate healthier thinking into their habits. I think a lot of people in charge of some of these programs don't understand that."

Some providers are beginning to reach out to the silent population. Alliance Medical Center received a grant to go into the farm worker community where they plan to do health screening and educate the population on the existence of the clinic. St. Joseph's Medical Access Program received a $500,000 grant from the California Endowment to fund a dental clinic van, which will go out into the community to offer dental care and education. The program also runs a medical unit that supplies the community with some medical care and education on issues such as cooking and prevention of diseases.

According to Ficco, St. Joseph's Medical Access Program supplies the only vans in the North Bay that directly reach the farm worker community.

"I think that Queen of the Valley would like to have a van, and the community has told them that a van would help," she says. "But many feel that the needs of the Hispanic population have been met. What they don't seem to understand is that the van reaches the population the clinics aren't reaching. We can provide newcomers with links to the clinics."

Sick Days

Healthcare rates are still rising. Insurance rates are expected to increase for the fourth year in a row to the highest amount yet--early numbers are indicating a 25 percent increase for HMOs in 2003. As rates continue to rise, fewer employers will be able to afford healthcare insurance, and those who continue to maintain insurance are likely to pass more of the burden on to the employees. Southwest Community Health Center is already seeing 200 to 300 more patients a month as more people without insurance seek care. Next year, the clinic expects to see more patients, including middle-class patients who can no longer afford premiums.

While rates are increasing, evidence suggests that the number of migrant workers coming into the two counties is increasing as well. The Press Democrat recently reported that the number of day laborers has increased to 120 in Graton and 200 in Fulton.

What does all this mean for the farm worker? As more Mexicans come in to the area and jobs remain tighter compared to earlier years, there will be more competition for jobs, lower wages, and less health insurance.

"The problem is likely to get worse for the migrant workers before it gets better," says Meckler.

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From the May 30-June 5, 2002 issue of the North Bay Bohemian.

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