Article from Streamline, November - December, Issue: Volume 16, Issue 6

MCN- Carolyn Davis, Family Nurse Practitioner, was awarded the Steve Shore Community Catalyst Award at the 2010 East Coast Migrant Stream Forum that took place in Charleston, SC, in October of this year. I first met Carolyn in 1997, when a group of us at MCN embarked on an epic journey in a rented RV from Austin, Texas to Ashville, North Carolina for another East Coast Migrant Stream Forum. I was five months pregnant with my first child, my husband was the volunteer driver, and along with three other women from the staff we set off for a two-week tour of health centers in seven southeastern states.

Our adventures were nearly halted in Eutaw, Alabama, when we realized that the shoestring operation we’d used to rent the RV didn’t actually have insurance that covered us. But our intrepid leader, Karen Mountain, figured out some way around that hurdle from her post in Austin and we continued eastward.

Every stop along the way was unique and we were awed by the creativity and dedication we witnessed at each subsequent health center. On day six we rolled into Beaufort, South Carolina, a bit road weary and overwhelmed by all we had seen. We parked our monstrous RV in the parking lot of Beaufort Jasper Hampton Comprehensive Health Services, Inc. and were met in the waiting room by the Migrant Health Coordinator, Carolyn Davis, the most gracious and enthusiastic person we had yet encountered in a trip full of wonderful people. Carolyn took one look at us and declared us in dire need of the best local fare. We followed her out through the beautiful flat coastal lowlands to a hole-in-thewall on the dock called The Shrimp Shack. The “Shack” specializes in shrimp burgers made from the fresh catch hauled onto the dock daily. Unfortunately they will not reveal their recipe, but to this day that is one of the best meals I have ever had.

Beaufort Jasper Hampton Comprehensive Health Services, Inc. is located in the midst of the “low country” of South Carolina. This is a beautiful part of the United States; a land of spreading moss-covered oak trees, palmettos and thousands of acres of stately southern pine. The marshy coastal region is made up of many small islands, including exclusive resort islands such as Hilton Head. From her home on a nearby island, Carolyn can hear the guns from the Marine training grounds on the neighboring Parris Island.

This region is also known for its agriculture, particularly for tomatoes and watermelon in the summer with winter vegetable crops such as winter squash, collard greens and sweet potatoes. Unlike some other regions of the country, the crops in this area of South Carolina are still largely worked by migrant farmworkers, many of whom travel up from Florida, others of whom come from Mexico, Central America, or Texas. Most of the migrants in this region are Hispanic families and young single people; however there is still a contingent of Haitian workers who primarily work in the packing sheds. Once the picking season is over in the Beaufort Jasper area, many of the same farmworkers travel further north to the Delmarva Peninsula where the season begins a couple of months later.

While agricultural employment has remained stable in this region, in recent years many migrants have also found work in the booming construction industry, particularly in the upscale resorts of the barrier islands. The increase in luxury housing on the barriers islands has moved more of the agricultural production inland. As Carolyn says, the islands now “grow more condos then veggies”.

Carolyn Davis did not start her career with the intention of working with migrant farmworkers. The daughter of a career Navy man, she moved regularly as a child, graduating from high school in Guantanamo Bay, Cuba. She received an associate degree in nursing from Florida Junior College, eventually graduating from the University of South Carolina with a BA and a Masters in Nursing. At that point she went to work for the local county hospital where she was the Director of Nursing.

In the early 1980’s, for a variety of reasons, Carolyn was looking for a change. She decided to explore the world of community health and left her job with the hospital to work for Beaufort Jasper Hampton Comprehensive Health Services, Inc. At the time she was unaware that there were even migrants in the area. The only thing she knew was that during the summer months hospital emergency room staff saw a jump in the number of people coming in. It took her only eight weeks to fall in love with the work and she has worked as the director of the migrant health program since that time. In addition to being the Migrant Health Coordinator, Carolyn was also
appointed the Director of Nursing for the health center. In the mid-90’s Carolyn went back to school and received her family nurse practitioner degree from the Medical University of South Carolina.

The migrant health program at Beaufort Jasper has grown tremendously and now serves farmworkers from three counties and a large number of migrant camps. The program runs year-round, but the biggest push comes during the 6-8 weeks of harvest time when there is a large influx of migrant workers. During this time, Carolyn brings in many different professionals from the community and the clinic to provide a wide array of services to the migrant patients. Most of these services are provided during the night clinic where they have seen as many as 87 people in one night. Carolyn says that the night clinic is “controlled chaos that somehow works”. She typically has people lining up to work in the migrant program long before the season begins.

In addition to the clinic time, Carolyn runs a number of outreach efforts in the migrant camps throughout the region. Outreach in the camps includes health education, screenings and mini physicals. When doing outreach, Carolyn often serves a number of different roles including advocacy, screening and referrals for further care.

One night a health center outreach worker called Carolyn in a panic to say that some of the farmworkers had been attacked by several members of the community. Carolyn drove out to the camp to investigate the situation and determined that everyone was safe and not badly injured. While there the farmworkers gave her a dog that had been traveling with them since Florida. She named the dog Dempsi, after the camp where the farmworkers had been living. Since that time she has rescued several other dogs from the camps.

Carolyn says that over the course of her career some things have improved for the migrant population while others have worsened. She believes that some of the prevention messages have made a real impact, especially in decreasing rates of sexually transmitted diseases and acute pesticide poisonings. At the same time, the migrants she sees continue to suffer from a number of musculoskeletal problems, dehydration and fatigue. Additionally, she sees more and more chronic disease, mirroring what is happening throughout the rest of the country, except that the patients she treats are often sicker and harder to manage. Finding specialty care is particularly difficult and Carolyn has to employ a number of different strategies to get people into care that they need.

A positive development has been the health center’s increasing use of MCN’s Health Network to help manage and track mobile patients. Carolyn says that Health Network “is a must for all of our diabetic patients, people with tuberculosis, our prenatal patients and anyone we screen for cancer.” In the past Carolyn says that she would have put off doing a mammogram for a woman she knew would be traveling soon, but since the advent of Health Network she knows that she will be able to find the woman and get her in care if necessary. Rosa Navarro, from the North Carolina Community Health Center Association (NCCHCA) tells the following story about Carolyn.

”When for any reason, she gets discouraged, she looks for a tree. Looking at a tree reminds her of one of the many individuals she has served. In 1986 during an evening clinic, a week before a group of farmworkers were scheduled to leave South Carolina, the physician noticed that a young man was having difficulty seeing. A visual test and health history revealed that he was almost blind and had been that way since childhood. He was able to work because he learned to use his other senses and because he had help from his co-workers. She remembered securing immediate, free consultation with an ophthalmologist by working with a local church to pay for glasses. When the young man used his eyeglasses, for the first time he noted the large object outside the window and exclaimed ‘tree’! This was the first time he had actually seen one in its entirety. Because he had never seen clearly in his life, he even had difficulty walking. Carolyn held his hand as he took his first unsteady steps. The sense of accomplishment has never abandoned Carolyn, because she believes that if she can help one person to see a tree for a first time, she can certainly line up the stars again to increase access and continuity of care for other farmworkers.”

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Excerpt of this article taken from: Liebman, Amy K. and Augustave, Wilson 'Agricultural Health and Safety: Incorporating the Worker Perspective', Journal of Agromedicine, 15:3, 192 - 199

“We are proud to be farmworkers and proud to work. We are not looking for handouts. Work gives us dignity. At the same time, when policies and laws are decided, it is important that you please include us in that process. It is more dignifying that way.” - Wilson Augustave

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In the United States there are between 1 and 2.5 million hired farmworkers,1,2 who earn their living from agriculture, one of the most hazardous occupations in this country.3 Largely from Mexico and other Central American countries, hired farmworkers make up approximately a third of the farm labor work force.1 In addition to hazards such as working with heavy machinery and arduous physical labor, farmworkers endure exposure to pesticides, risk of heat illness, and often inadequate sanitary and housing facilities. Factors such as lack of training, poor safety precautions, language barriers, piece-rate pay, undocumented worker status, and geographical and cultural isolation can put these workers at increased risk for occupationally related injuries and illnesses and abuses. Farmworkers also face obstacles in obtaining health care due to high costs, lack of insurance, geographical isolation, and language as well as cultural barriers.

Despite the inherent dangers of farm work and the unique vulnerabilities of farmworkers, US health and safety regulations and labor laws for agriculture offer less protection to farm laborers than workers in other industries. There is a long history of farmworker exceptionalism under the law. However, this was not always the case. In the 19th century, living and working conditions in agriculture were not strikingly different than in other industries. Work in many industries, including agriculture, was characterized by hazardous and often primitive working conditions, long hours, and meager wages. Child labor was common and many workers endured extreme poverty. Immigrants, willing to accept low wages and dangerous work, supplied the labor for both agriculture and other industries.4 As other industries began to see greater protection, agriculture remained unchanged.

Reforms made during the Progressive Era through the New Deal period had a dramatic impact that transformed industrial labor in the 20th century. Child labor was prohibited or severely restricted in most industries. Overtime pay requirements helped limit the number of hours worked and minimum wage laws helped lift many laborers from crushing poverty. Workers' compensation laws ensured that workers injured on the job received medical care and payment for lost income. Moreover, industrial workers were granted the right to collectively bargain and be protected from employer reprisals. As a result of these changes, the standard of living of industrial workers improved dramatically.4

Download the full article Liebman, Amy K. and Augustave, Wilson 'Agricultural Health and Safety: Incorporating the Worker Perspective', Journal of Agromedicine, 15:3, 192 - 199

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I was amazed today to be copied on an email about a big concern about the emergency response of the influenza team in Eastern Europe. I was copied because of the possibility that we may need to quickly mobilize a training of rural providers on the recognition and treatment of the potential severe complications of H1N1.

It is rather fascinating now how the world has become smaller and smaller and that communications are so rapid that literally on a daily basis we are getting very accurate reports of severe outbreaks in small communities all over the world.

I have also been present for some very high level discussions about how much where resources should be deployed. Like any other large organization it is astonishing to see that at WHO sometimes petty politics and personalities get in the way of rational evidence based science and humanitarian response.

I just found out that I will be presenting the results of our training efforts and the concept of the Clinicians Manual at an annual clinical meeting of the Asian component of the WHO in Manila in about 10 days and will also be doing a full day training of the manual at the IUATLD in Cancun in December. It also amazes me how in just 2 months they have managed to insert me into a very responsible role here and I see the same thing happening with my colleagues especially this incredible family physician from South Africa who has only been here since June after 23 years on the front lines in the "bush" dealing with a population with almost a 40% HIV positive rate and tons of MDR and now XDRTB.

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Dr. Ed Zuroweste, MCN’s Cheif Medical Officer, has been deployed to the World Health Organization (WHO) in Geneva, Switzerland for four months to assist healthcare providers in limited resource settings.

The WHO asked Dr. Zuroweste to serve as a Special Medical Consultant to assist with revision and field testing of the WHO Clinicians Manual for the treatment of the most common diseases in adults in limited resource setting. The manual places particular emphasis on emergency treatment of complications of the H1N1 (Swine flu) influenza. The WHO team has just finished the first pilot testing of the manual in Uganda and Dr. Zuroweste will be a part of the next phase of testing in Ethiopia. He is also likely to be conducting field tests of the teaching of the manual in Asia and other parts of Africa.

The WHO specifically sought out a primary care physician with experience working in low resource communities both in the US and abroad. Dr. Zuroweste’s 20 plus years of providing migrant care, extensive background in offering technical assistance to migrant health centers and clinicians on the front lines, the impressive success of MCN’s Health Network and his work in Honduras teaching Johns Hopkins medical students in an impoverished rural sector of the country all contributed to his selection for this assignment.

We are all very excited about this opportunity and challenge and eagerly await updates from Dr. Zuroweste as he travels the world! Stay tuned for periodic updates from Dr. Zuroweste from his international assignment.

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It often seems that the most innovative programs develop out of the most hopeless seeming situations. The world of migrant health is full of examples of individuals who see a great need and then employ creative thinking and action to right a wrong. In a world where we too often run up against an intractable bureaucracy, these examples of creative problem solving are a breath of fresh air. Some of the most inspired thinking in migrant health comes out of the 22 Migrant Voucher Programs that exist nationwide. All of the voucher programs coordinate, facilitate, and provide access to primary health care for farmworkers by purchasing, rather than providing directly, some or all of the primary care services required. In many ways these voucher programs are one of the best models for public-private partnerships found in primary care for the underserved. As Susan Bauer, Executive Director for Community Health Partnerships of Illinois says, “When vouchers come to town, private providers become partners in our health systems and we gain extree into the wider community of support for migrants”. As economic times get more difficult, imagination in health care is even more important to reach out to the hardest to treat among us. You can find out more about these programs here.

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