Being a clinician in a migrant health setting can be different from doing the same job in a more traditional setting. The statements below are from different migrant health service providers. Each professional talks about the experience they have had after choosing to apply their talents and training to work with migrant and seasonal farmworkers.

Physicians

Dennis Penzell, Florida

A professional career in migrant health entails some of the most challenging patients as well as medical and social complexities which can be found in contemporary medicine.

A new provider is first challenged by a culture with beliefs and practices foreign to their own and frequently contradictory to the dogma of our professional education. A clear understanding of how these beliefs interplay with a diagnostic and treatment regimen is essential to establishing and maintaining wellness and the successful treatment of the patient. Sensitivity, respect and acknowledgment of those beliefs is essential in establishing trust and rapport.

The new provider is challenged, secondly, by the living and social situations or our migrant patients. These are quite different from those situations of patients cared for during professional school and postgraduate training. The lack of adequate housing, appropriate sanitary conditions, refrigeration, heat and air conditioning play an integral part in the complexities of caring for our patients.

The third unique aspect of medicine which a new clinician will confront is the exposure of our patients to chemicals, pesticides and other toxic materials in the environment. Probably the most dramatic, emotional, and challenging experience I have faced during my career with migrant and seasonal farmworkers occurred during the treatment and follow up of 84 migrant workers following the largest pesticide accident to occur in Florida and possibly the country. This incident dramatized many of the issues and problems seem by clinicians in migrant health, including lack of education on health issues (protective clothing, food washing, reentering sprayed fields too soon). The deficiencies in our legal system regarding the protection of farmworkers was exemplified by the shortage of investigators and the lack of enforcement of existing laws regarding worker safety and health.

These deficiencies were, however, balanced by the faith, trust, respect and confidence the farmworkers placed in myself and our staff. This was a most gratifying experience. Several elderly patients were specially accommodated with regard to scheduling, etc. due to multiple health problems. I explained that I was here for them, that they were my patients, and were important to me. They then began to cry. I guess no one had ever taken an interest in their lives, their health, and their well-being. Had anyone ever related to them as human beings?

By far the greatest rewards of this profession are the gratitude, the appreciation, and the thanks we receive from our migrant patients. In no other professional experience have I felt the affection, respect and warmth that I feel with these clients.

Finally, working in migrant health medicine allows me the opportunity to teach medical students and residents about farmworkers, to open their eyes not only to the medical and social necessities, but to nurture the compassion and sensitivity necessary to work with farmworkers. This will carry over to their work with other ethnic groups, minorities, and people of different cultures.

I explain to all students and residents that the lessons learned in working with migrant farmworkers are lessons of more than just complex medical care. They are lessons of tolerance and of dignity. In short, they are lessons of integrity, lessons of justice, and lessons of life.

Nurses

Joyce Seavecki, Michigan

First of all, a nurse should expect the unexpected. Because of the migratory way of life for the migrant worker, they do not always know where they will be next week or next month; therefore, we must understand that they do not always have their medical records, immunization records, or income records.

I have been the outreach coordinator for nine years at our clinic and my job duties include supervising the outreach workers who register patients in about 20 different counties in Wisconsin. I have to direct them to the camps and factories and the times which are most convenient for them to register the people and their families for services. this means much communication with the grower or crew leader.

We do school screening, which includes children ages 6 weeks to 12 years. This not only includes physicals, but immunization, TB testing, lead screens and education. We have a team of Nurse Practitioners who do the actual physicals, nurses who do the immunizations, and our school team of university students who do the vision, hearing, blood pressures and Spanish translation for the nurses who are usually not bilingual. I go to the [schools} and coordinate these services and help with the screenings.

We also have a Primary Care Mobile Unit that goes directly to the farm camps and factories, and I coordinate these services. We do Paps, breast exams with vouchers for mammograms, blood pressure, blood sugars, hemoglobins, and any primary care services which with the nurse practitioners who go with us need help. These hours are very irregular, depending on what time the workers get in from the fields and what time the shifts are at the factories. Because of the distances we travel, we work anywhere from eight to twelve hours a day.

The most rewarding part of the job is bringing health services to the underserved and uninsured. The people are so gracious and appreciative of whatever services we provide.

Outreach Workers

Colin Austin, North Carolina

When I started working as an outreach coordinator, I had trouble conceptualizing my role. I was unsure about expectations, and how to accomplish even simple things like meeting farmworkers. For a few weeks I suffered from "outreach anxiety". Slowly, by going to trainings and learning about my area I became more comfortable with my job description.

What exactly is outreach anyway? A lot of confusion exists because outreach workers are often temporary and they operate outside the clinical setting. Because outreach workers go to where farmworkers live and work they are often the first point of contact into the health care system. Part educator, part social worker, part advocate, part friend, the outreach worker sounds like some sort of mythical creature. In an age of increased specialization, it may be difficult to conceptualize the many roles that outreach workers play. An encounter with a farmworker outside of the clinic is a valuable moment. In a more natural and relaxed setting, outreach workers have time to talk with individuals and groups about their backgrounds, health problems, and perceived needs. When you sit down with a farmworker there is a window of opportunity to gather information and create a health impact.

Outreach work is not a 9-to-5 job. Outreach efforts may just be beginning when most clinical staff are going home -- during the late afternoons, evenings, and week-ends. Sometimes outreach workers can reach farmworkers on lunch breaks, but most often after they have returned from work in the field. This means that outreach workers are often out late. You can find outreach staff at churches, flea markets, soccer matches, laundromats, and other places where farmworkers gather.

One thing that outreach workers do is tell farmworkers about the clinic and local health services. Farmworkers can identify the outreach worker as a friendly representative from the clinic -- someone that cares and a name that they can use if they do need help. While visiting farmworkers where they live and work, outreach staff can also perform health screenings. A lot of health education occurs on outreach. With almost every outreach encounter, educational material and information can be distributed. Outreach workers may also conduct educational presentations in labor camps or other places that farmworkers gather. Through outreach, farmworkers themselves may be trained to be trainers and create lay health advisor programs.

By being on the front line, outreach workers have an opportunity to provide many direct services and to respond to the various barriers that farmworkers face. A farmworker may need help obtaining social services, housing, education, transportation, interpreter services, or hospital care. This can be overwhelming. The outreach staff should carefully establish a system and policies for conducting case management. But this type of individual assistance is an essential component of comprehensive care; the help of an outreach worker often makes the absolute difference between a client accessing or going without a needed service. Outreach workers also look for ways to work with other organizations to better serve farmworkers.

In all their roles, it is critical that outreach workers document their efforts. Outreach workers usually only get credit for a small percentage of the work that they do. Consistent gathering of demographics and health status information can also help the clinic focus their health care efforts.

Outreach is more like a process than a one-time treatment. The need to revise and improve is constant. Operating a good outreach program is a long-term process. It is unlikely that you can develop a full range of outreach services in a single summer. Being effective requires building relationships with farmworkers, growers, and local service providers. The outreach worker needs training and practice as a health educator and case manager.

Health Educators

Michele Collins, South Carolina

My experience is that of a health educator working in a community health center. As the only staff proficient in Spanish working with a farmworker population that was predominantly Latino and mono-lingual Spanish, there were many responsibilities that were added to my daily routine, such as scheduling and translating appointments.

My responsibilities included educating the community about the farmworkers who came annually to work there, and I soon realized that working with the wider community and the health center were just as important as my work with farmworkers. I was an important resource to both parts of the community, a cultural broker of sorts, and my work in the community could help build a more supportive, healthy environment for the farmworkers who came there to work.

There are many challenges I dealt with on a day-to-day basis: trying to plan educational activities for a population that is spread out and often isolated; working with local growers and health center staff to help them understand the strengths and needs of farmworkers; and, perhaps most challenging, trying to address some of the bigger issues in the community that affected health (like discrimination based on ethnicity and class, hazardous working conditions and poor housing), while still meeting the immediate needs. The biggest challenge for me was to learn that I can not do everything. The health needs of farmworkers can be overwhelming, especially if you are the sole health educator who is both planning and providing educational programs to the population in an area. I had to assess how to maximize my time and reach the most numbers of people.

While the needs are overwhelming, the rewards are pretty fantastic. Building relationships and developing trust with people was the most rewarding part of my job. The relationships I built with the farmworkers with whom I was working helped me sustain myself when I was feeling overwhelmed, burned out, and ineffective. I know beyond a shadow of a doubt that I loved my job with a passion, and, knowing what I do now, I would definitely choose to work again as a health educator with farmworkers. (Michele Collins is currently at the University of North Carolina completing an MPH.)

Dentists

Horace Harris, North Carolina

I have found, in my seven years as Dental Director at a community health center, that the oral health needs of this population are great. Most patients access the clinic when experiencing dental pain associated with severe caries or periodontal disease. It has been our goal to alleviate the emergency pain and then encourage the patient to return for follow-up treatment, stressing prevention through good oral hygiene and nutrition.

Educating the patient on proper oral hygiene has been a challenge. Many adult patients have received dental treatment in their native country that is, unfortunately, of poor quality, leading to severe caries and perio disease. Babies are often given bottles with sugar water or sweet colas at night, causing severe decay on upper anterior teeth known as Baby Bottle Tooth Decay.

To address these problems, we have a team approach at our health center. All health providers (physicians, Physician Assistants, nurses) as well as maternal and child health care coordinators and outreach personnel help the dental staff by detecting dental disease early and referring to dental for treatment. This team approach promotes dental awareness and improves accessibility to services.

Many of our patients receive Medicaid assistance for dental treatment. However, few private dentists in our area accept new Medicaid patients due to low reimbursement rates. Therefore, we are overwhelmed by the number of dental patients needing dental treatment.

The most rewarding aspect of providing dental services to this population is their sense of appreciation for treatment, and the opportunity to make a positive impact by improving the oral health of a population with great needs.

Certified Nurse Midwives

Candace Kugel, Pennsylvania

I work as a Certified Nurse-Midwife at an upstream Community and Migrant Health Center. With every migrant woman I encounter I find myself stretching and reshaping the philosophical idealism of nurse-midwifery. Flexibility and openness are my goals, while protocols and risk criteria become difficult to standardize.

Although I do not feel we are particularly well-prepared for the task of caring for migrant women, I do feel that CNM's are well-suited for this work. A migrant woman has never challenged my credentials or asked to be seen by a "real doctor." Most are visibly relieved to learn that they will be cared for by a woman. When I have faced discussing abortion with a Haitian woman through and interpreter; or providing the first pelvic examination for a Mexican woman who has already had six children; or developing a management plan for a woman who is post-term had a previous cesarean section, and is living in a car with her small child and unemployed husband, I know that I am as capable as any other provider to stumble through these interactions.

Since farmworkers come to our area for only four months of the year, it is rare that I care for a migrant woman through her entire pregnancy. I may diagnose her pregnancy, I may see her for three or four prenatal visits (augmenting my data base with records she has brought from another location), or I may meet her only once before she goes into labor and delivers here baby. Migrant families have at times chosen to stay in our area until the baby is born, but usually leave before the baby's two-week check up. I struggle with the desire to make a difference in a short period of time and with the disappointment of not being able to follow-through.

It is difficult to really prepare a nurse-midwife new to migrant health. What you can certainly expect are unbelievable clinical challenges and cultural adventures.

Clinic Directors

Willa Hayes, Michigan

In orienting clinicians new to health care for farmworkers, I believe you need two approaches: a) one type of orientation for resident localities, and b) another for the "upstream" projects/ agencies who see an evolving wave of migrating farm workers with very brief stays in a given area. Having said that, some of my 27 years in this field in an "upstream" Migrant Health Center have led me to list the following recommendations when recruiting and selecting clinicians:

1. Do not hesitate to appeal t the humanitarian, altruistic side of a clinician.
2. Select and nurture those clinicians who are challenged and inspired by improvisation.
3. Expect to have to provide times for de-briefing, especially in the turbulent, hectic and demanding milieu of a Migrant Health Center.

Relative to the priority of orientation issues, I have tried two approaches: a) a careful, thoughtful and didactic orientation with written objectives and b) brief overview followed by immersion. Guess which has consistently worked best? The "on-the-job" training or orientation really works best, especially when you can pair a new clinician with a veteran.

Teach and encourage new clinicians to establish a realistic time frame with which they have to work with clients. All of the elaborate standards of care , care plans and case-management plans will go for naught is the recipient of your caring is only in your physical, geographic locale for a week or ten days. This is hardest to convey to newly turned-out clinicians, and may require daily reviews of their work by a peer. Veteran or experienced clinicians ten to adapt better to the helter-skelter lifestyle of the farm worker. I usually scatter through my orientation sessions frequent reminders of the disparity between the agenda of the farm worker and the rather ideal and lofty agenda of the clinician/ health care center. We are to defer to the farm worker's agenda, for the most part.

Encourage clinicians to trust the old diagnostic skills of palpation, percussion, auscultation and careful listening. Exhaustive laboratory work or radiology studies are not likely to be welcomed by farm workers who seek relief of symptoms so that they may return to work. Recognize that the achievement of comprehensive care for episodic patients is not going to occur very often.

There are many things I could list, but perhaps the most important advice I have to give to new clinicians is to demonstrate respect. Be warm and interested in the whole family. If you do not speak Spanish or Creole, work with translators who understand how you work. Use translators as "pass-throughs" or vehicles to get the information out and in. Eye contact and touch are crucial. Learning to be clinically relevant as ell as competent utilizing a translator is an art, and takes time and experience to hone. Learning some phrases or some of the most frequently asked questions in the language of the farm worker should be encouraged. Event the attempt to speak the patient's language will build trust and confidence.

These harvesters of the nation's food are very bright and resourceful people who travel great distances and undergo severe deprivation in order to work. The nobility of this pursuit is getting short shrift in the press and legislative bodies today, but the sheer enormity f the service this group of oppressed people do for the rest of us need to be acknowledged and honored by the clinicians who will provide primary health care to them and theirs.