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By student from Miami, Rachel Becker
A paucity of literature provides an in-depth exploration of the mental and physical health of migrant workers. Researchers and clinicians have a variety of unanswered questions that could help them better serve this community, ranging from methods of health promotion to help-seeking behaviors to resiliency factors. High quality research will not only provide them with a better understanding of this population, but also assist them in tailoring their efforts and interventions.
Given the historical trauma, marginalization, and disenfranchisement of migrant workers, research frameworks must empower communities to have a strong voice in the focus, process, and dissemination of research. Without this type of paradigm, the best-intentioned research projects can maintain the status quo, silencing and pathologizing the community. Furthermore, without extensive community input the results of research might not have strong validity and applicability. In this article, we outline community-based participatory research (CBPR) methodology that privileges the needs and input of the community throughout the entire research process. We, undergraduate and graduate students at the University of Miami, are currently working with the Everglades Community Association (ECA; a migrant worker camp) and EnFamilia (a community organization that provides a wide range of services to ECA) to examine aspects of educational attainment and mental health. We will use our experiences in our current work to illustrate the core elements of CBPR and to provide other practitioners with ideas on how to incorporate these principles into their clinical work and research.
Before initiating research, we focused on building relationships with different community partners. By focusing on building alliances and identifying key stakeholders, CBPR ensures that researchers stay grounded in the community instead of locked away in ivory towers. The second step formalizes this process and provides a foundation of community input that will shape and guide the research throughout the project. During this stage, we formed a community advisory board (CAB). For us, this group included the heads of EnFamilia, who are not only service providers, but are also on the board for ECA. The CAB is a core guiding force that helps to ensure that the community’s needs, not those of outside groups (e.g., a university) or those only perceived by service providers, are the focus of research. Additionally, the CAB co-creates the focus of the research, data collection methods, analysis, and how the data will be reported and used within the community. In a fully developed article, we will outline each of these steps in more detail and illustrate each phase with lessons learned from our own experiences.
MCN Honors Workers on International Workers' Memorial Day, Children in Agriculture Have Unequal Protections
On the heels of International Worker Memorial Day, the day slated to honor the ultimate sacrifice of workers and families throughout the world, the Obama administration released a statement saying it will no longer pursue protections for children working in agriculture. MCN is deeply saddened that children working in agriculture still lack equal protections under the law as compared to children working in all other industries.
The Department of Labor’s (DOL)Wage and Hour Division (WHD) on Thursday announced it is withdrawing proposed revisions to child labor regulations in the Fair Labor Standards Act that would have provided additional protections to children hired for work in agriculture.
Protecting Working Children in Agriculture
Amy K. Liebman, director of MCN’s environmental and occupational health initiatives told Bloomberg's Occupational Safety and Health Reporter that the (Obama) administration still must address why children hired to work on farms do not have the same safety protection of youth in other jobs.
"This is a real disservice to the migrant child," Liebman told BNA April 27. "For any child who is employed (in agriculture), they are basically being neglected by this process."
The Fair Labor Standards Act sets age 12 as the legal limit for farm work with exemptions available for children as young as age 10 or 11, according to the National Center for Farmworker Health. The organization estimates that up to 300,000 children under age 18 perform dangerous and strenuous work on US farms, annually.
"We have a subpopulation of very young workers (in agriculture)," said Celeste Monforton, Assistant Research Professor in the Department of Environmental and Occupational Health at The George Washington University School of Public Health. "Public health science showed these youth workers were at risk and preventative measures could protect these workers," she said.
Migrant children and the children of migrant and seasonal farmworkers - who are often hired for work in agriculture - are particulary vulnerable to harsh working conditions and will continue to face unequal protections given DOL's announcement. Poverty, migration patterns, weak labor protections and disparate or a dearth of formal education leave migrant children and families few options.
In April, the National Children's Center for Rural and Agricultural Health and Safety published the 2012 National Blueprint for Protecting Children in Agriculture. MCN's Liebman was an author on the report, which outlines goals and strategies for reducing injuries and deaths among children on farms.
Proposed Child Labor Rules Changes
The proposed rules amended exisitng Hazardous Orders governing child labor in both agricultural and non-agricultural sectors and included provisions prohibiting children under 16 years of age hired for farm work from operating heavy machinery and performing certain high-hazard tasks.
Under the proposed revisions, hired children under 16 years of age would have been barred from working as pesticide handlers, operating trenchers or earthmoving equipment, fork lifts, potato and grain combines and tractors over 20 horsepower. Children would have also been excluded from work in manure pits or inside of fruit, forage or grain storage designed to retain an oxygen deficient or toxic atmosphere. The rules would have also prevented hired kids under 16 from driving a bus, truck or automobile when transporting other passengers and required tractors operated by children to be equiped with a Rollover Protection Structure.
Farms with less than 10 employees and children of farm owners or farm operators would have been exempt from the proposed rules changes. Additionally, the proposed rules afforded exemptions to youth involved in educational programs.
According to Monforton, the proposed child labor rules changes were under development for nearly 15 years were originally based on reports published by the National Institute of Occupational Safety and Health and the Institute of Medicine to bring parity between the protections afforded to children hired for work in agriculture and other industries.
Kids Still at Risk
In its statement, DOL said it will partner with industry stakeholders and organizations like 4-H "to develop an educational program to reduce accidents to young workers and promote safer agricultural working practices."
Monforton and others contend that the reason the rules were proposed is because injuries and deaths still occur even with voluntary education programs in place.
According to the National Farm Medicine Center's 2011 Childhood Agricultural Injuries Fact Sheet, agriculture has the second highest fatality rate among youth workers with 21.3 deaths per 100,000 full-time workers, compared to an average 3.6 deaths per 100,000 workers in all other industries.
- The Huffington Post published a story about the proposed rules.
- Celeste Monforton is an author at The Pump Handle blog
- Farmworker Justice published a blog post about the DOL reversal.
As part of our series of continuing education webinars, MCN partnered with the National Farm Medicine Center and Agrisafe Network in March to present the Nuts & Bolts of Cholinesterase Monitoring for Farmers, Ranchers and Agricultural Workers. The webinar – archived on the MCN website – provides a comprehensive overview of cholinesterase monitoring and its application in the primary care setting, including a review of the history of cholinesterase monitoring, best practices for whom and when to test, types of cholinesterase and what to measure, obtaining baselines, the role of the clinician in protecting workers and reporting pesticide exposures.
In conjunction with the webinar, MCN and its partners also unveiled our latest pair of clinical tools – the Cholinesterase Testing Protocol for Health Care Providers and the Cholinesterase Testing Protocol Algorithm. The cholinesterase protocol and algorithm, according to Carolyn Sheridan, RN, BSN, Clinical Director at Agrisafe Network, are helpful, simple tools in a concise format for clinicians to use as guides.
“The algorithm and protocols are straightforward tools to use to manage care,” she said.
Sheridan, along with Matthew Keifer, MD, MPH, Director of the National Farm Medicine Center and with additional support from MCN's Amy K. Liebman, MPA, MA, reviewed seven cholinesterase monitoring protocols to develop a more comprehensive tool.
The protocol and algorithm provide clinicians with practical answers to questions regarding all aspects of the plan of care, including testing, follow-up care and managing patients’ return to work, according to Sheridan.
Experts in environmental and occupational health, pesticides, migrant health and agricultural health and safety peer-reviewed the newly developed tools, which also received the endorsement of MCN’s Environmental and Occupational Health Advisory Committee.
More about Organophosphates, Cholinesterase and ChE Monitoring
Two of the more toxic classes of insecticides in use today – Organophosphates (OP) and N-methyl-carbamates (CM) – were born from the research of German scientist Gerhard Schrader and have similar origins to other toxic nervous gasses he discovered during his research.
The OP and CM classes of insecticides both act to inhibit an important enzyme in the functioning of the nervous system called cholinesterase. Monitoring the levels of cholinesterase in patients working with these chemicals is a way clinicians can help protect workers and diagnose acute overexposure.
The two types of cholinesterase present in the human body are acetylcholinesterase (red blood cell (RBC) cholinesterase – AChE) and butyl cholinesterase (plasma cholinesterase – PChE). The RBC or AChE is generally less susceptible to inhibition from OP exposure and more robust than is PChE, though both should be monitored.
During MCN’s webinar, Dr. Keifer makes the case for cholinesterase monitoring in terms of worker protection, listing the following potential benefits that can result:
- Removing overexposed workers before illness begins
- Identifying failures in worker protection systems
- Raising awareness of hazards of the chemicals monitored
- Diagnosing acute overexposures
- Driving the financial equation toward the use and development of safer chemicals
During the month of March, MCN is taking the opportunity to share with you a series of blog posts about poisonings and poison prevention. This week marks the 50th Anniversary of National Poison Prevention Week and MCN wants to highlight a range of topics around this emerging issue.
Poisonings became the leading cause of injury death in the United States in 2008 and nearly 9 of 10 poisoning deaths are now caused by drugs, according to a December 2011 Centers for Disease Control and Prevention report.
The CDC defines a poison as any substance that is harmful to the body when ingested, inhaled, injected or absorbed through the skin. Unintentional poisonings occur when the individual exposed to the substance is not attempting to cause harm to themselves or others.
The nation's 57 Poison Control Centers fielded more than 2.4 million calls related to human poison exposuresArizona, Florida, Louisiana, New Mexico, Tennessee and Washington were among 20 states in which the poisoning death rate was significantly higher than the national average rate of 13.4 deaths per 100,000 persons, according to the report. Poisoning was the leading cause of injury death in 30 US states, 14 of which boasted a poisoning death rate above the national average.
A North Carolina Department of Health and Human Services 2010 study reports that unintentional poisonings in that state exceeded deaths from hypertension, atherosclerosis, homicide, HIV and liver disease.
Unintentional Drug Poisonings and Deaths
The rate of deaths due to unintentional drug poisonings more than doubled in a ten-year period, rising from 4 deaths per 100,000 persons in 1999 to 9.2 in 2008, according to the CDC report.
CDC data shows drug poisoning deaths have remained steady over a 10 year period from 1999 – 2008 among Hispanic populations, but rose sharply among non-Hispanic white, American Indian and Alaska Native populations. The rate of drug poisoning deaths involving opiod analgesics saw a 40 percent increase during this same period increasing from about 4,000 to 14,800, accounting for 40 percent of drug-related poisonings in 2008.
Children Are At-Risk for Poisonings
Children are not immune from dangers of unintentional poisonings and exposure. According to the Maryland Poison Center website, more than 1 million suspected poisoning exposures in children ages 6 and younger are reported to poison centers across the country annually and more than half of all poison exposures occur in children.
Children too suffer from unintentional poisonings and deaths from medications. Safe Kids USA, in its March 2012 report on medications and child safety, finds that unintentional child poisoning deaths due to medications nearly doubled between 1979 and 2006, increasing from 36 percent to 64 percent. In Washington State, cosmetics, analgesics, household cleaning substances, foreign items (toys, miscellaneous) and topical preparations were the top five sources of poison exposures in children under six years of age.
How to report a suspected poisoning?
Call 1-800-222-1222 to contact your local Poison Control Center (services provided in 150 languages).
CLINICIANS: Suspect a pesticide exposure? Use MCN's Pesticide Reporting Map to learn how to report pesticide exposures in your state.
MCN and others have several online resources to educate people about poisoning and prevention.
- Conozca a sus medicamentos is an educational podcast conveying the importance of being aware of and sharing information about medications.
- Poco Veneno… ¿No Mata? is one of several of MCN's educational Spanish language comic books with information about preventing pesticide poisonings.
- The website KidsHealth offers tips for preventing poisonings among children.
- The EPA offers tips to help prevent pesticide poisonings in the home.
The National Poisoning Data System Top 10 Human Exposure Categories for Pharmaceuticals:
3. Other Antihistamines Alone
4. Selective Serotonin Reuptake Inhibitors
5. Atypical Antipsychotics
6. Diaper Care and Rash Products
7. Ethanol (Beverages)
8. Systematic Antibiotic Preparations (Oral, Intravenous, Intramuscular)
9. Acetaminophen (alone, adult)
10. Diphenhydramine (alone, unknown if OTC or RX)
Each year the CDC holds a national poster contest for to help engage youth in poison prevention. You can see this year's winning poster from an 8th grader in North Carolina.
One of my colleagues at MCN has recently reminded us of the need to tell the stories of the people that we encounter and the work that we do. So often we put our nose to the grindstone and don’t look up to appreciate and share with others the stories we hear of day-to-day struggles and success. Fortunately, this past summer we had the pleasure of working with an intern from Chico State named Joel Zorillo who spent his time with us collecting stories to share.
The following account comes from a participant in MCN’s Hombres Unidos program. The program trains migrant men to be advocates for violence prevention in their own communities. It is one of MCN’s success stories as a program and we have good evaluation data to show significant changes in behavior. But what it is really much more interesting and exciting to hear individual accounts like the one transcribed here.
Fernando Garcia (not his real name)
One day I was lying down, and I noticed that my wife had not come to bed. I went to the living room and found her crying on the sofa; I thought to myself, “Oh, someone must have died”. When I asked her what was wrong, she said: “Fernando your daughter has something important to tell you”. I turned to my daughter, whose face was turned away from me and was also crying. I asked her what was wrong, knowing already what she was about to say. “Dad, I’m pregnant”. As she said this she recoiled as if I was going to strike her, or yell at her. But instead I kneeled down and hugged her, and said: “don’t worry I’m not angry at you for telling me this; this obviously wasn’t planned but I support you entirely in whatever decision you make”. I told her that this house is her house if she decides to stay, nothing will change. And if she decides to marry this boy who is the father that’s fine too, as long as it was her own decision and she was happy with it. Of course I set this down with one condition, that no matter what, she has to finish her high school career before anything.
A couple weeks later, the family of my daughter’s boyfriend came up to visit from Mexico. They immediately proposed throwing a party and plan the wedding to celebrate the union of the couple. I intervened and made my opinion clear: getting married was a decision that had to be made entirely by the two of them, not me, not his parents, not anyone but my daughter and her boyfriend.
The truth is that my experience with the Hombres Unidos workshop had a huge impact on me. It taught me to control my emotions, and this came through in how I dealt with my daughter on the day she told me she was pregnant. It taught me to deal with my emotions and how to talk to my family. Overall it was a learning experience in which I discovered new ideas and concepts in terms of family violence and how to avoid it at all costs. I am not and was never a violent person, but it still changed my attitude toward my family and our interactions within the family in a more peaceful manner. And for this I thank those who organized the Hombres Unidos workshop, especially Luis Vasquez and those who helped him.
“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
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
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.