The Health and Well-being of North Carolina's Farmworkers

Health Risks Facing Migrant Farmworkers

Health risks are associated with farmworkers' living and working environments. Agriculture is one of the most dangerous industries in the United States [4]. In 2017, it had the highest rate of fatal occupational injuries with 23 deaths per 100,000 full-time equivalent workers compared with a rate of 12.9 in mining, quarrying, and oil and gas and 15.1 in transportation and warehousing (see Figure 3). In addition to fatalities due to heavy equipment and transportation, heat stroke is another leading cause of death among agricultural workers. According to the Centers for Disease Control and Prevention (CDC), farmworkers die from heat-related illness at a rate 20 times greater than that of the entire US civilian workforce [5]. North Carolina, Florida, and California lead the nation in heat-related fatalities among farmworkers [5]. H2A workers are particularly susceptible to heat illness because many start work immediately upon arrival to North Carolina without a period of acclimation to the state's heat. The availability of water breaks varies significantly, and shade is often scarce in the fields. As one farmworker interviewed by an intern with Durham-based Student Action with Farmworkers said: “We were all shaking because it was so hot, almost dehydrated. You know what I did? I left them… It was less than an hour before finishing, and I thought for $6 I am not going to die here. I'm leaving. In the field, there were no shade trees. It is just a ditch full of weeds, but that's where I stayed, and it didn't matter if there were snakes or thorns. It didn't matter… All I wanted was shade.”

• Download figure
• Open in new tab
• Download powerpoint

FIGURE 3.

Rate of Fatal Work Injuries by Industry, 2017

Other occupational illnesses faced by farmworkers include increased rates of respiratory illness, noise-induced hearing loss, skin disorders, and pesticide exposure [6]. Symptoms of acute pesticide poisoning range from respiratory failure, seizures, and death, to nonspecific symptoms such as nausea, vomiting, intestinal cramping, and eye irritation [7]. Long-term health effects of chronic pesticide exposure include certain cancers, Parkinson's disease, memory loss, and depression [8]. Children of farmworkers are particularly vulnerable to pesticide exposure. They are exposed to pesticides in multiple venues including while working in the fields, living in housing located in the fields, and through pesticides inadvertently brought home on their parents' clothing and shoes. Current regulations allow youths as young as 14 to be employed as hired farmworkers without parental permission; youths aged 10 to 13 can be employed as hired farmworkers with parental permission [9]. Additionally, sometimes the youngest children accompany their parents to work due to lack of child care [10]. The National Institute for Occupational Safety and Health (NIOSH) estimates that hundreds of thousands of children under age 18 work in US agriculture each year, but there is no comprehensive estimate of the number of child farmworkers in the United States [11]. Pesticide exposures in children are especially significant since children have a greater surface to volume ratio than do adults and achieve absorption of disproportionately higher level of pesticides. They also metabolize toxins more slowly than do adults, so the pesticide dose they receive remains with them longer [12]. Additionally, their immature nervous systems are susceptible to permanent damage from pesticide exposures [13]. Women also experience reproductive complications due to pesticide exposure, including increased risk of infertility, premature delivery, and infants with congenital defects [13, 14]. Green tobacco sickness is another occupational illness caused by the absorption of nicotine through the skin while working with tobacco. This causes dizziness, vomiting, muscle cramps, anorexia, and insomnia. One North Carolina study showed that 24% of tobacco workers suffer from green tobacco sickness at least once in a growing season [15].

Migrant housing, including barracks, trailers, houses, and other structures, can pose health hazards, especially if it does not meet the minimum standards established in migrant housing regulations. Gentry et al. found that most dwellings in their study did not meet the US Department of Housing and Urban Development's minimum criteria for health and safety [16]. Vallejos et al. found that of the 43 migrant homes examined in North Carolina in 2008, only 11% met the migrant labor housing standard, with 67% found to be moderately substandard, and 22% severely substandard [17]. Violations included overcrowding, structural problems, and lack of required facilities and appliances [17]. In addition, because migrant housing often lacks air conditioning, the in-home temperatures can be over 100 degrees, making it difficult to cool down after long work days in high temperatures, which significantly contributes to heat illness [18]. These conditions can increase the risk for not only physical illness such as pesticide exposure and infectious diseases, but also emotional illness such as depression and anxiety [19].

Adding to the burden of physical and emotional disease, immigrant farmworkers often face isolation, fear regarding immigration status, discrimination, and separation from family, all of which can result in loneliness, depression, anxiety, substance use, and other behavioral health concerns. Research shows extremely high rates of depression and anxiety among North Carolina farmworkers, with a prevalence of over 50% in one study [20]. Female farmworkers again face unique risks. In one study of California female farmworkers, 80% reported some form of sexual harassment, including 24% reporting sexual coercion or on-the-job blackmail affecting their physical and psychological health [21]. In this study, women field laborers experienced headaches (49%), trouble sleeping (52%), shaking hands (51%), perspiring or sweaty hands (49%), heart palpitations (48%), and chronic tiredness (48%) as a result of their harassment [21].

Legal and Policy Gaps

Many of the occupational risks experienced by farmworkers result from the lack of legal protections and the lack of resources to enforce existing protections. For example, the federal Worker Protection Standard (WPS) is intended to reduce the risks of pesticide exposure among agricultural workers. However, it is dependent upon workers receiving and understanding the required WPS training and farm owners complying with the regulations. These include providing protective equipment when required, abiding by the listed re-entry intervals after pesticide application, and providing the required water stations and hygiene facilities [22]. Additionally, there are very few WPS or housing inspectors in North Carolina, making enforcement of both the WPS and the housing regulations difficult. Finally, there are no federal or North Carolina state occupational safety and health standards that address heat illness [23]. California, Washington, and Minnesota are the only states to currently have such legislation.

In the 1930s agriculture was excluded from almost all federal labor laws created to protect workers, leading to what is now referred to as “agricultural exceptionalism.” The National Labor Relations Act of 1935 excluded farmworkers from the right to act collectively to form unions. The Fair Labor Standards Act of 1938, which originally excluded all farmworkers from minimum wage protections, now only requires agricultural workers on large farms to be paid the minimum wage. This act also excluded most farmworkers from receiving overtime pay and allows children as young as age 12 to work in agriculture, not age 16 as in other jobs [24]. Despite the dangers inherent in their work, most workers are not covered by workers' compensation insurance, as it is limited to H2A workers and those who work on a farm with 10 or more year-round employees.

Current Services

Under the Public Health Service Act, the Health Resources and Services Administration (HRSA) provides federal funds to FQHCs to provide high-quality medical, dental, and behavioral health services to underserved communities in rural and urban areas [25]. Some health centers receive Migrant Health Center Program funding designated for farmworkers in order to respond to the unique needs and barriers they experience. In North Carolina, there are 39 FQHCs, 12 of which are funded to increase access to care for farmworkers and their family members. The Office of Rural Health's NCFHP is one of these 12 centers, considered by HRSA as a Migrant Health Voucher Program. Unlike a free-standing health center, NCFHP's service delivery model involves contracting with agencies throughout the state to provide and leverage comprehensive health services for farmworkers in regions where there are significant unmet needs. The model relies heavily on enabling services through outreach staff who identify farmworker patients, assess their needs, manage referrals, and are essential members of the medical care team for patients with chronic illnesses and other significant health needs. NCFHP and its network of service providers and partners served a total of 10,060 patients in 2017 [26]. The unique model allows for the flexibility to expand, decrease, and move services as the needs in communities throughout North Carolina change.

In 2017, all FQHCs with targeted services for farmworkers served a total of 48,090 farmworker patients and their dependents. Of these patients, 79% received an enabling service (health education and case management), 40% had a medical visit, 9.5% a dental service, 1.8% a mental health service, and 0.17% a substance abuse service (Uniform Data System, Roll Up Report for North Carolina Migrant Health Centers, unpublished data, 2017). Of the farmworkers and their family members who had a medical visit at an FQHC in North Carolina, being overweight or obese, hypertensive, or diabetic were the top three most common diagnoses (Uniform Data System, Roll Up Report for North Carolina Migrant Health Centers, unpublished data, 2017). Similarly, in 2015, 25.6% of all the farmworkers seen by NCFHP had blood pressures greater than 140/90 and 79% had a body mass index over 24 (Reinsvold M, master of public health thesis, UNC Gillings School of Global Public Health, unpublished data, 2016). Not surprisingly, among the 250 MSFWs surveyed in 2018 by NCFHP, the most frequently requested additional health education was on diabetes, hypertension, and nutrition (NCFHP, internal farmworker feedback survey, unpublished data, 2018).

Despite these targeted services, access to health care services by farmworkers remains limited, especially in counties where there are no targeted services or where the size of the population is extremely large. Based on our population estimates inclusive of farmworker families, fewer than 37% of the population received any service from an FQHC in 2017 (Uniform Data System, Roll Up Report for North Carolina Migrant Health Centers, unpublished data, 2017). Barriers to care include: cost, transportation, hours of operation, inability to miss work, fear, lack of awareness of available services, and language and cultural differences. The top three barriers to care cited by farmworkers served by NCFHP in 2018 were transportation, language, and cost (Lipscomb, A, NCFHP Farmworker Feedback Survey Results, unpublished data, 2018). Health care providers also have difficulty serving farmworkers, many of whom are unable to leave work during daylight hours and whose frequent migration for work makes continuity of care for chronic or complex health conditions challenging. Referring patients for specialty services is especially difficult because these services are often only available during the work day, in English, and without a sliding fee scale for patients without insurance. In addition, having an H2A visa is a barrier to eligibility for some hospital charity care programs because the expectation is that workers will have insurance through the Affordable Care Act. However, although North Carolina has been a leader in farmworkers' enrollment in insurance, most H2A workers are not enrolled during the short time they reside in North Carolina.