Global Health at Your Doorstep

A family carrying water

In a climate-altered and migration-rich world, clinicians in rural areas across the United States are witnessing global health issues in their own small communities. Simultaneously, clinicians continue to grapple with the rapidly changing landscape of COVID-19 and seasonal infectious diseases. Here are some updates on health issues that continue to impact agricultural workers and other vulnerable members of our communities.

COVID

Almost 9,400 people die in the United States every month from COVID. As data are compiled, researchers are gaining an improved understanding of the impact of long COVID, treatments like Paxlovid, and the effectiveness of the bivalent vaccine. Here are brief updates on some leading COVID-related concerns for clinicians to understand to better serve their migrant agricultural worker communities and other underserved populations.

Long COVID

Also known as post-COVID conditions, long COVID affected roughly 16 million working-age adults in the United States as of summer 2022, with between two and four million unable to work because of the condition.¹ Additionally, a new cohort study out of Germany found that children and adolescents had a similar rate of long COVID as adults – with children and adolescents 30% more likely than the control group to experience health issues in like with long COVID, compared to 33% for adults.² However, long COVID affects certain groups of people more than others. People with severe acute COVID, those with comorbidities like diabetes, unvaccinated people, and those who experienced multisystem inflammatory syndrome (MIS) during or after acute COVID are more likely to develop long COVID.³ Early and severe racial inequities in acute COVID infection have dissipated as vaccines and health interventions have succeeded,⁴ yet inequities in long COVID linger, as long COVID falls disproportionately on adults already experiencing other health, work, and social disparities. For example, those who work from home and/or at a seated location like a desk may be able to rest or recuperate during work hours, whereas those who cannot work from home and/or work in a more active job may not be able to rest or take additional needed breaks. Additionally, lower-income jobs may lack paid time off or sick leave. In one study, 20% of Latinx adults reported long COVID symptoms after COVID infection, compared to 14% of Asian adults and 14% of white adults.⁵ This may further “exacerbate health, employment, and income disparities among this group, who were already harder hit by the pandemic,” one report concluded.⁶

Paxlovid

One promising medication to prevent long COVID is Paxlovid (ritonavir-boosted nirmatrelvir), a treatment for acute COVID which has been shown to reduce the risk of hospitalization and death from COVID by 89% in unvaccinated patients with a higher risk of disease.⁷ A pre-print release of a study from the Veterans Health Administration found that Paxlovid treatment may reduce the risk of the development of long COVID symptoms like heart concerns and breathing irregularities after the acute phase of the virus has concluded. These findings were evident among vaccinated and unvaccinated patients. Research limitations include the population studied, which is predominantly male and white. Paxlovid is now available without cost at pharmacies across the country. Despite early efforts to promote Paxlovid in low-income and underserved communities, however, a CDC Morbidity and Mortality Weekly Report from October 2022 found that, between April and July 2022, the percentage of Hispanic COVID patients receiving Paxlovid was 30% lower than among white and non-Hispanic patients⁸. Media reports on “Paxlovid rebound” or “COVID rebound” in which patients experience recurrent but milder COVID symptoms after initial recovery, and/or viral detection after a negative test, may discourage patients from requesting Paxlovid; however, patients should be informed that “rebound” occurs in a small percentage of cases and does not appear to be associated with a progression to severe COVID.⁹

RSV and Other Seasonal Viruses

An early-season increase in respiratory syncytial virus (RSV) is placing additional stress on health care systems, as other respiratory and seasonal viruses similarly ramp up. RSV in particular is sending more pediatric patients to hospitals around the country. For the past two years, respiratory disease activity has been largely a result of COVID, with seasonal flu and RSV at historic lows. However, by November 2022, increases in RSV, flu, and rhinovirus/enterovirus (RV/EV) were much higher than usual, particularly among children, the Centers for Disease Control and Prevention reported. This may indicate a more severe flu year, and hospitals are already becoming full with RSV pediatric patients across the country. Fortunately, families are now well versed in prevention measures including mask-wearing and frequent handwashing. Other COVID-prevention techniques like increased ventilation in shared spaces, or quarantining and isolation, can further protect at-risk family members like young children (particularly from RSV) and older adults.

Demographic Shifts at the US-Mexico Border

In 2022, the demographics of asylum seekers at the US-Mexico border changed, and policy shifts may once again cause significant demographic shifts. Political and economic instability have driven Venezuelans to make the dangerous migration across Central America and Mexico to request asylum in record numbers. In fiscal year 2018, US authorities had fewer than 100 encounters with Venezuelans; that number increased to almost 188,000 Venezuelans in fiscal year 2022.¹⁰ However, following a Biden Administration shift in policy in October, Venezuelans asking for asylum are being turned away under Title 42, a health policy used to prevent the spread of COVID-19. A November 2022 court ruling to vacate Title 42 may once again affect border crossings. In the meantime, 24,000 Venezuelans under a new policy may apply for refugee status, for those with a US-based sponsor.¹¹ Additionally, Ukrainians have arrived as refugees at the US-Mexico border, as have tens of thousands of migrants from Cuba, Nicaragua, Haiti, Mexico, and the Northern Triangle of Guatemala, Honduras, and El Salvador, with a record total of over two million encounters in fiscal year 2022.¹² A third of those encounters were repeat encounters, inferring that at least a third of people who are turned away at the border try again.^13,14 At least 853 migrants died crossing the US-Mexico border during fiscal year 2022, yet another record,¹⁵ and a reminder for clinicians across the country of the precarious, dangerous, and traumatizing migrations that many newly arrived immigrants and asylum seekers have endured. Trauma-informed, culturally attuned care at health centers will continue to play a critical role to ensure community health.

Valley Fever, Heat, and Climate Change

Climate change continues to increase the health risks of agricultural workers and other low-income and poorly protected workers. Valley Fever, or coccidioidomycosis or “cocci”, is a fungal infection from the inhalation of Coccidioides spores in disturbed soil or dust. The fungus lives in the soil in many parts of the southwestern United States, particularly in southern Arizona and California’s San Joaquin Valley, as well as parts of Mexico and Central and South America; it was also recently discovered in the soil in Washington state as well. Agricultural workers are particularly at risk when tilling or using equipment that disturbs the soil and causes dust to circulate in the air. Symptoms include fever, cough, shortness of breath, rheumatism, rash, and fatigue. Most illnesses occur one to three weeks after fungal exposure; however, some infections can return months or years after initial infection. People with weakened immune systems; people with diabetes; pregnant people; and people who are Black or Filipino have a higher risk for developing the severe form of Valley Fever. Valley Fever should be on the differential diagnosis when a patient presents with possible pneumonia or COVID-19, and who has been in the geographic region where the fungus is present. As many cases occur in drier months, many cases do not coincide with the flu season, but as the West has fewer winter rains, the possibility of winter Valley Fever is increased. Valley Fever is reportable in many states.¹⁶

The number of cases each year is increasing, from under 2000 cases in the year 2000, to over 20,000 cases reported in 2019. The CDC believes this is a vast undercount, with estimates of true case numbers in the hundreds of thousands, and the potential range of the Coccidioides may be larger, encompassing the entire West. ¹⁷ As a result of climate change, many parts of the southwest continue to experience drier than average and hotter than average seasons, year after year, resulting in drier soil for more months of the year that is more likely to become airborne when disturbed by industrial farm equipment.

Of course, the rise in global temperatures as well as more frequent and more severe heatwaves increase the risk of heat-related illnesses and kidney disease among agricultural workers. Risk factors include dehydration, breathability of clothing, workload, and piece-rate payment. Without federal heat standards, agricultural workers may be protected by state-level heat standards, or not at all. Heat standards can implement critical preventative measures like access to water, rest, and shade.

These climate-related concerns are only some of the many health risks that agricultural workers and other vulnerable populations face as the climate crisis deepens. Social risk factors like poverty, migration, unsafe and unprotected working conditions, unsafe or insufficient housing, access to health care, language, and literacy can amplify vulnerabilities when a climate-fueled extreme or disaster occurs. US island territories like the Marshall Islands, on the other hand, are battling saltwater intrusion on freshwater sources, and sea level rise impact on agricultural lands. As the climate crisis progresses, entire island communities may be displaced; many are already migrating to agricultural areas like Hawaii.

In addition to the recognition of these increased risks, clinicians must serve agricultural workers’ daily needs during climate-fueled crises and their short- and long-term recovery from climate disasters. A health center-wide commitment to emergency management plans can begin to account for and center the community’s most vulnerable.