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Protecting Pregnant Agricultural Workers: Medical-Legal Partnership in California

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medical legal partnership

 

I
n the spring, the California Department
of Pesticide Regulation announced that
209 million pounds of pesticide active
ingredients were used in 2016 across the
green fields of the Golden State, ranking
2016 as the third highest-use year on
record. In Monterey County, in California’s
fog-defined Central Coast where lettuce and
other greens grow year-round, nine million
pounds of pesticide active ingredients were
applied, an increase of four percent over
2015.
1 That same year, ten of the 30 zip
codes with the heaviest pesticide use in
California were located in Monterey County
– and more than 18,000 students attend
school next to fields that spray highly haz-
ardous pesticides – the most of any county.
2
With such intensive and growing pesticide
usage comes a myriad of health concerns.
“It’s a huge issue in agricultural communi-
ties – not just in California, but all across the
US,” says Aaron Voit, Esq., the Equal Justice
Works Fellow for California Rural Legal
Assistance (CRLA) who has made pesticide
exposure in Monterey County the focus of a
new medical-legal partnership. CRLA and the
Monterey County Health Department have
teamed up to eventually provide legal servic-
es to pesticide-exposed patients at all of the
county health department’s nine community
health center look-alike clinics, which serve
roughly 170,000 people per year.
Like many medical-legal partnerships, Voit
aims to address systems-wide issues while also
providing legal assistance to individual
patients. CRLA has a long history of agricultur-
al worker advocacy, Voit says, “so when it
came time to think about how we could
deepen our efforts to work on pesticide expo-
sure, it became clear that one of the pieces
that was missing was direct intervention for
victims of pesticide exposure.” Migrant
Clinicians Network, which has worked directly
with frontline providers to help them better
recognize, manage, treat, and report pesticide
exposure in the primary care setting for over
15 years, applauds CRLA’s efforts.
“It’s important for primary care clinicians in
farming communities to rapidly recognize and
treat pesticide exposure and prevent delays in
diagnosis, which may help victims avoid long-
term disability or other harm,” noted Laszlo
Madaras, MD, MPH, MCN’s Co-Chief Medical
Officer and a clinician in a large farming com-
munity in south-central Pennsylvania. “A good
first step is being aware enough to ask the
right questions during the initial taking of his-
tory. MCN has been collaborating with com-
munity health centers on the training of these
efforts – and it’s great to see CRLA taking up
the charge as well.”
The partnership’s first priority is for the
most vulnerable in the fields: agricultural
worker women who are pregnant. The
Center for the Health Assessment of Mothers
and Children of Salinas (CHAMACOS), which
has been studying the health impacts of pes-
ticides in Salinas Valley for years, has put out
a longitudinal study that found that seven-
year-olds whose mothers experienced pesti-
cide exposure while pregnant had impair-
ment in cognitive functions and verbal com-
prehension, among other health complica-
tions like decreased lung function.
3,4
Under California’s state disability insur-
ance law, pregnant women can typically
receive replacement income for missed work
for up to four weeks prior to the due date,
but exposure earlier in pregnancy can have
significant and lasting impacts on the child’s
health and development.
“Doctors are allowed to certify pregnant
women for disability benefits if they think it’s
a high-risk pregnancy,” he said, and there’s
now literature out there to make the case
that working in the fields while pregnant
presents an undue health risk to women and
their babies, thanks to the CHAMACOS
studies. Voit is using the CHAMACOS study
results to help protect the children of the
very community that CHAMACOS is study-
ing. “Many of the doctors I work with
[obtained] the blood and urine samples for
that study,” Voit said.
Voit has provided trainings with these same
clinicians to identify who is at risk and help
shepherd those patients through the process
to help each patient determine what path –
with a mix of paid and unpaid leave, for exam-
ple – works best for her. The first step is identi-
fying agricultural worker women of reproduc-
tive age. (For that, Voit used MCN’s agricul-
tural worker identification resource; see
“Resources” below.) After the women are iden-
tified, clinicians must take an exposure history
to determine their risk level. If their risk is high,
they can be referred to Voit, who can provide
information on what potential leave options
they have, which can get complicated. “It’s not
a one-size-fits-all,” explained Voit. As long as a
woman qualifies for state disability insurance –
meaning that she has at some point paid into
the system – she can receive her weekly benefit
amount for up to 52 weeks, regardless of how
much she’s paid into the system. “Even so, we
still do individual assessments so that women
can understand how much paid and unpaid

In the spring, the California Department of Pesticide Regulation announced that 209 million pounds of pesticide active ingredients were used in 2016 across the green fields of the Golden State, ranking 2016 as the third highest-use year on record. In Monterey County, in California’s fog-defined Central Coast where lettuce and other greens grow year-round, nine million pounds of pesticide active ingredients were applied, an increase of four percent over 2015.1 That same year, ten of the 30 zipcodes with the heaviest pesticide use in California were located in Monterey County– and more than 18,000 students attend school next to fields that spray highly hazardous pesticides – the most of any county.2 With such intensive and growing pesticide usage comes a myriad of health concerns.

“It’s a huge issue in agricultural communities – not just in California, but all across the US,” says Aaron Voit, Esq., the Equal Justice Works Fellow for California Rural Legal Assistance (CRLA) who has made pesticide exposure in Monterey County the focus of a new medical-legal partnership. CRLA and the Monterey County Health Department have teamed up to eventually provide legal services to pesticide-exposed patients at all of the county health department’s nine community health center look-alike clinics, which serve roughly 170,000 people per year.

Like many medical-legal partnerships, Voit aims to address systems-wide issues while also providing legal assistance to individual patients. CRLA has a long history of agricultural worker advocacy, Voit says, “so when it came time to think about how we could deepen our efforts to work on pesticide exposure, it became clear that one of the pieces that was missing was direct intervention for victims of pesticide exposure.” Migrant Clinicians Network, which has worked directly with frontline providers to help them better recognize, manage, treat, and report pesticide exposure in the primary care setting for over 15 years, applauds CRLA’s efforts.

“It’s important for primary care clinicians in farming communities to rapidly recognize and treat pesticide exposure and prevent delays in diagnosis, which may help victims avoid long-term disability or other harm,” noted Laszlo Madaras, MD, MPH, MCN’s Co-Chief Medical Officer and a clinician in a large farming community in south-central Pennsylvania. “A good first step is being aware enough to ask the right questions during the initial taking of history. MCN has been collaborating with community health centers on the training of these efforts – and it’s great to see CRLA taking up the charge as well."

The partnership’s first priority is for the most vulnerable in the fields: agricultural worker women who are pregnant. The Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), which has been studying the health impacts of pesticides in Salinas Valley for years, has put out a longitudinal study that found that seven-year-olds whose mothers experienced pesticide exposure while pregnant had impairment in cognitive functions and verbal com-prehension, among other health complica-tions like decreased lung function.3,4

Under California’s state disability insurance law, pregnant women can typically receive replacement income for missed work for up to four weeks prior to the due date, but exposure earlier in pregnancy can have significant and lasting impacts on the child’s health and development. “Doctors are allowed to certify pregnant women for disability benefits if they think it’s a high-risk pregnancy,” he said, and there’s now literature out there to make the case that working in the fields while pregnant presents an undue health risk to women and their babies, thanks to the CHAMACOS studies. Voit is using the CHAMACOS study results to help protect the children of the very community that CHAMACOS is studying. “Many of the doctors I work with [obtained] the blood and urine samples for that study,” Voit said.

Voit has provided trainings with these same clinicians to identify who is at risk and help shepherd those patients through the process to help each patient determine what path – with a mix of paid and unpaid leave, for example – works best for her. The first step is identifying agricultural worker women of reproductive age. (For that, Voit used MCN’s agricultural worker identification resource; see “Resources” below.) After the women are identified, clinicians must take an exposure history to determine their risk level. If their risk is high, they can be referred to Voit, who can provide information on what potential leave options they have, which can get complicated. “It’s not a one-size-fits-all,” explained Voit. As long as a woman qualifies for state disability insurance –meaning that she has at some point paid in to the system – she can receive her weekly benefit amount for up to 52 weeks, regardless of how much she’s paid into the system. “Even so, we still do individual assessments so that women can understand how much paid and unpaid leave are available to them, and to make sure that their paid leave is available to them when they most need it,” Voit said. Few families can take much unpaid leave due to economic pressures, and each state varies in how much unpaid family leave is permitted – additional factors to consider.

“It’s important to sit down individually with women and see what’s available to them and come up with a paid and unpaid leave plan for their pregnancy,” Voit noted. In addition to exploring potential leave plans, women must be given full information on the risks of pesticide exposure, particularly to children in the womb. The medical-legal partnership, Voit says, ultimately aims to “inform women of their risks and equip them with the information and the financial opportunity to make the best decisions that they can.”

The medical-legal partnership has big plans. While he’s currently stationed on-site in one of Monterey County’s health centers, Voit has the ultimate goal to “firmly establish this practice here in Monterey County, and then to spread it to other farmworker communities in California.”

In addition to individually assisting hundreds of agricultural pregnant women over the course of his fellowship, Voit is also developing tools and resources to help any patient who has been acutely exposed to pesticides to navigate the legal avenues toward reparation. He also hopes to eventually expand into other contamination concerns, including water contamination. In Monterey County, agricultural worker housing has routinely been in the spotlight for high levels of nitrates coming out of agricultural worker housing spigots, and Voit recognizes that many in the community have legal needs around the continuing harm that such contaminants present to agricultural worker health. Voit, for one, is enthusiastic for the work to come.

“We’re looking at a model to open up doors in a different way, so that we can both reach people who are exposed and come up with new remedies that aren’t currently available,” Voit shared. “Because the ones that are available now aren’t working well.”

 

Here are a few resources that Voit recommends.

The American College of Obstetricians and Gynecologists committee opinion on Employment Considerations During Pregnancy calls out legal means as a way to address pesticide exposure.
Available at: https://bit.ly/2NNLLLZ.

A recent Slate article, “Why Some Doctor’s Offices Double as Legal Clinics,” covered medical-legal partnerships for pregnant women:
https://slate.com/human-interest/2018/04/why-some-doctors-offices-double-as-legal-clinics.html.

Pregnant@Work is “a resource that can help providers write effective notes for pregnancy accomodation on behalf of their patients,” Voit said.
Available at: https://www.pregnantatwork.org/healthcare-professionals/pregnancy/

MCN’s mobile and seasonal agricultural worker identification resource is available at:
https://bit.ly/2JXXUvu.

Visit Equal Justice Works at http://www.equaljusticeworks.org/

Visit California Rural Legal Assistance at http://www.crla.org/.

This section is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS09742, Technical Assistance to Community and Migrant Health Centers and Homeless for $1,094,709.00 with 0% of the total NCA project financed with nonfederal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

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