There is great concern from clinicians we talk to that many of the migrants we serve, specifically those who work for large agricultural companies that raise and slaughter pigs and chickens (CAFOs-- concentrated animal feeding operations) are at high risk for not only contracting H1N1 but also because of frequent migration and crowded living conditions they are likely to spread the virus rapidly. Even a greater “theoretical concern” that we have is that these workers may be a source of new novel more virulent strains of the H1N1 virus because of their constant daily close exposure to pigs and chickens. We have tried to explain to the CDC, NIOSH, OSHA that this group of workers should be in the category of “high risk” and therefore eligible for both early vaccine and treatment if illness occurs.

Unfortunately, we have been unsuccessful for a variety of reasons. This population, as you probably know, are for the vast majority, recent immigrants and frequently undocumented. So, it is always “controversial” when we try to highlight this population.

A recent article: http://www.ehponline.org/members/2009/117-9/focus.html more completely describes many of my concerns.

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When discussing farmworker health risks, we include language and cultural barriers to health care access as well as the inherent risks of farmwork. We also recognize important factors such as avoidable pesticide exposure and other unsafe working conditions; poverty aggravated by exploitative wages and pay theft; unsanitary working and living conditions; and stress related to job insecurity, poverty, and lack of control of one’s own life circumstances. Contributing to each of these is the unique social position of the migrant farmworker, which Southern Poverty Law Center and others have described as “close to slavery.” Indeed, the relationship we generally see between the grower or contractor and the migrant farmworker has many of the characteristics of 19th century slavery. It is common for the grower or contractor to control not only the wages, conditions, and activities of farmworkers during working hours, but also their living conditions (often serving as landlord), what and when they eat, with whom they may associate, and when and where they may go outside of working hours. Fear of deportation or retaliation by their employers makes it difficult for workers to complain about pay issues, unsafe working conditions, unsanitary living conditions, or other forms of mistreatment. Access to information about available social and medical services may also be controlled by the employers. When outreach services such as medical care are available for farmworkers, access to them is too often controlled by the grower or contractor as well. Even in cases where workers are treated “humanely,” their freedom is still significantly limited by a large and unfair power differential.

Health professionals who care for migrant and seasonal farmworkers are very familiar with this situation. The “almost slave-master” relationship is spoken of openly, and often with an air of resignation, at regional and national forums. However, its underlying effect on the health of our patients and our obligation to address it as a healthcare issue are less often discussed and are not unanimously accepted. Some view the problem as beyond our scope, and others see it as simply an untreatable condition. A few even seem to believe that migrant farmworkers for some reason do not quite have the right to be treated the same as other patients. These attitudes lead unfortunately and inevitably to a paradoxical situation in which healthcare workers –who may be staunch advocates for their patients’ health when it involves prescribing medications or providing health education – become unwitting collaborators in perpetuating the underlying condition that contributes to so many of the farmworker’s health problems.

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In 1992, Congress passed legislation for HRSA through the Bureau of Primary Health Care to institute a Federal Government Self-insured malpractice program that was named “Federal Tort Claims Act (FTCA program). Since its inception in 1992 there has now been an estimated cost savings of $1.6 BILLION. That means that this money has been poured back into health centers and healthcare for the poor instead of to the very profitable malpractice insurance companies.

I wonder what would happen if the US had a healthcare system based on CHCs where all providers were covered by FTCA??? How many health care dollars would then be diverted from private malpractice insurance and into healthcare for all!!!!!!

From 2002-2007 the number of claims per million patient encounters has decreased from 6.2 to 3.8 which is a remarkable 38% DECREASE!!!

There has also been a steady growth in cost savings each of the past 5 years ($164 million in 2002 to $193 million in 2007). This has all been accomplished “during a period of time when the demands of increased exposure stemming from higher patient volume and greater complexity of care delivery”.

FTCA helps all of us when we are out there selling a career in migrant/community health centers. We can now truly state that this malpractice insurance (FTCA) is the best malpractice insurance a provider can have. Why?? Because it costs the health center and provider nothing, there is no upper limit to the claim so there is no liability at all to the providers and there is no time limit on your coverage (you are covered for life for all of the time you were covered by FTCA at your health center (i.e. no “tail coverage” necessary). And if you are unfortunate enough to be involved in a malpractice case you will be defended in Federal Court by an expert Federal Malpractice Attorney.

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MCN was featured in an American Public Health Association (APHA) blog for our conference session entitled “Dying to Work: The Risks from Injury and Death on the Migrant’s Journey to Work in the United States,”

In their entry, APHA highlights the work of MCN staff member, Amy Liebman, who said that despite a nearly ninefold increase in funding for the U.S. Customs and Border Patrol since 1993, the agency’s strategy of preventing illegal immigration through deterrence has failed. This shift in the border patrol’s strategy in 1993 helped create an even more vulnerable population of immigrants coming to the United States by making it more treacherous to cross the border, but at the same time, not decreasing the prevalence of illegal immigration. The end effect was more migrants diverted into harsh, rugged areas such as the southern Arizona desert and an increase in the number of deaths and injuries.

Once migrants enter the United States and begin working, often in the construction, agriculture and meatpacking industries, their lives don’t get any easier. Liebman called them a “hyper-exploited” work force, vulnerable to safety violations in the workplace and at heightened risk of injury and mortality.

APHA then raises the question of the role of politicized debate in public health. What are your thoughts?

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I have been following this story in The Washington Post and The NYT. I feel that I have to share it with you all. There are now at least 13 pork processing workers being diagnosed with a new disease, Progressive Inflammatory Neuropathy. What makes it so interesting is that it came to light because a medical INTERPRETER working with Spanish speaking meat packers noticed that two patients she interpreted for had similar, serious health problems. This is a fascinating case both from a cultural competency perspective/interpreting services and an occupational medicine/health and safety perspective. What a great pick up by an interpreter!

Long time health and safety activist, Jordan Barab, wrote the following:

Don’t Snort Pig Brains

Oh, and it turns out that inhaling vaporized pig brains is probably bad for workers – not that anyone thought to figure this out before requiring workers to remove the pigs’ brains with compressed air forced into the skull through the hole where the spinal cord enters

Was this problem discovered by the company, or occupational health experts? No. An interpreter working with Spanish-speaking patients at a medical clinic in southern Minnesota heard the same story about strange health problems from two Minnesota pig processing workers doing the same job.

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