Health & Occupational Safety

Pesticides and Puerto Rico: When the Professional Becomes Personal

I had the privilege of participating in the East Coast Migrant Stream Forum for Agricultural Worker Health in Atlanta earlier this month. The annual Forum brings together outreach workers, advocates, medical professionals and many others who provide crucial health services to farmworkers. It is a great opportunity to learn from those who are working with farmworker communities on the ground, as well as share updates on what is happening at the federal level.

This year, one of my presentations focused on pesticide safety, including recent revisions to the Environmental Protection Agency (EPA)’s Worker Protection Standard (WPS) and best practices for identifying and treating pesticide exposure. I co-presented with Alma Galvan, Senior Program Manager of Environmental and Occupational Health at the Migrant Clinicians Network (MCN), and Dr. Jose Rodriguez, MD, Chief Medical Officer at the Castañer General Hospital in Lares, Puerto Rico.  

This was where the professional and personal collided for me. You see, I was born and raised in Hormigueros, Puerto Rico, a small town on the island’s west side, not too far from where Dr. Rodriguez lives and works. My parents, siblings, extended family and friends still live on the island. As a teenager, I often went camping in the mountains of Adjuntas, one of the five rural municipalities covered by Castañer General Hospital’s services.  

During the three weeks between Hurricane Maria’s landfall and our scheduled presentation, communication with Dr. Rodriguez, as with a lot of people on the island, was virtually nonexistent. We had resigned ourselves to doing the presentation without him, and then just a few days before the event, he was able to let us know that he was still planning to come. His arrival in Atlanta was no small feat given conditions on the island, but then again, Dr. Rodriguez is accustomed to producing miraculous results amidst seemingly hopeless circumstances.

Earlier this year, Hospital General Castañer received the EPA’s Environmental Champion Award for outstanding commitment to protecting and enhancing environmental quality and public health. Dr. Rodriguez is a leader in the identification and treatment of pesticide exposure, as well as other occupational health issues. He is a dedicated family physician and passionate advocate for his community. During our presentation, Dr. Rodriguez stressed the important role of community health advocates and local hospitals in identifying pesticide incidents and gathering and recording key information that can serve not only for more effective medical treatment, but also to support future legal and advocacy work.

During the Forum’s plenary session, Dr. Rodriguez also shared pictures of his hometown – bare trees, downed electricity poles, streams where roads used to be. He highlighted the most recent official statistics – almost half the population on the island still had no running water, and approximately 90% still had no electricity. The numbers themselves are staggering, but the many human examples of what those numbers mean are truly overwhelming. Another staggering statistic: approximately 80% of the island’s agriculture was decimated by the storm, including the island’s coffee, tropical fruit and poultry farms. As I write this a week later, I would love to report that much progress has been made, but based on information from both family updates and media reporting, that would be woefully inaccurate.  

Dr. Rodriguez also cautioned all of us about the impending public health emergency that looms over the island as recovery advances in fits and starts. He worries that the floods and landslides will lead to pesticide drift in both soil and water, including wells. Mosquito-borne illnesses like Zika, where much progress had been made before, may reappear as stagnant water remains. A lack of basic hygiene may give rise to communicable diseases, while malnutrition and a lack of potable water, especially among children and the elderly, will inevitably have significant health effects. Outbreaks of conjunctivitis and leptospirosis (a bacterial disease caused by contaminated water) have already been reported and many hospitals are only able to operate partially due to the lack of electricity and a shortage of medical supplies.

Amidst this dire picture, I am reassured by the work of individuals like Dr. Rodriguez, countless heroes who may never get recognition from a federal agency for providing such essential services to their communities, including farmworkers. The hurricane in Puerto Rico and other recent natural disasters in California, Texas and Florida have quite literally laid bare many of the inequalities and dangers that farmworkers face every day. This past month has been very difficult for many, but it has also reaffirmed the importance of fighting for farmworker communities – communities who are intimately familiar with both nature’s capacity for capriciousness and humans’ capacity for resilience.     

You can donate to Puerto Rican relief efforts through the Hispanic Federation.



The CMS’ Marketplace Stabilization Rule – What You Need to Know to Help Farmworkers Access Health Insurance

On April 13, the Centers for Medicare and Medicaid Services (CMS) released a final rule regarding market stabilization within the health insurance marketplace.[i] The rule makes several changes to current ACA provisions, including open enrollment, Special Enrollment Periods, and guaranteed availability, among others. It is likely that these changes will make access to health insurance more difficult for eligible farmworkers and their families.

Perhaps one of the most significant changes made in the rule is the shorter timeframe for open enrollment 2018. Like past open enrollment periods, this year’s open enrollment period was supposed to be from November 1st, 2017 to January 31st, 2018. Now, open enrollment 2018 will end six weeks sooner on Dec. 15th. Farmworkers, especially those who are limited English proficient or lack familiarity with the U.S. health care system, rely on in-person assistance to successfully enroll in health insurance through the marketplace. Farmworker enrollment efforts are often more time-intensive, requiring several appointments pre- and post-enrollment. Assuming that there are no changes in navigator funding, it will be critical that outreach and enrollment programs in farmworker communities are prepared to provide the same level of assistance within a shorter timeframe.

The rule also re-interprets the ACA’s guaranteed availability provision. Insurers are required to accept all consumers who enrolled, regardless of past payment history. Now, under the rule, insurers can penalize new consumers who re-enroll in health insurance and have premium debt from the last 12 months.[ii] Farmworkers who migrate or lack access to postal services may inadvertently miss a premium payment. Some farmworkers will need assistance to make timely monthly premium payments in order to avoid any future penalty.

Lastly, the rule made several changes to eligibility and enrollment during special enrollment periods (SEPs). Beginning in June, 100% pre-enrollment verification will be required for enrollment outside of the open enrollment period due to a permanent move, loss of minimum essential coverage, or Medicaid/CHIP denial. Enrollment will be pended until the verification process is complete, which involves submitting supporting documents to the marketplace (either online or by mail) within 30 days. This presents an enormous challenge to farmworkers, especially migratory workers and workers in the U.S. on H-2A temporary work visas, who may not have access to documents like leases or utility bills, or may not live in places where these documents are in their name. Fortunately, CMS recognized that not all consumers will be able to fulfill the verification requirements. CMS will implement “reasonable flexibility” that will allow individuals to send a letter about their situation if they are not able to provide sufficient supporting documentation. This may be an important tool for farmworker consumers who are unable to provide supporting documentation regarding their SEP eligibility.

Farmworkers and their families, given the risky and low-paying nature of farm work, need affordable and accessible healthcare options. The final CMS rule presents a new set of obstacles for farmworkers to obtain affordable health insurance. Assisters in farmworker communities will need to develop strategies to overcome these obstacles and maintain access to health insurance for eligible farmworkers and their families. FJ will continue to provide timely information around issues that affect farmworker access to health insurance.


[i] You can find the final rule at

[ii] The penalty would be added to their monthly premium and would only apply to consumers who are applying for health insurance with the same issuer or an issuer in the same control group.

Health: National Farmworker Awareness Week 2017

Day 5 of National Farmworker Awareness Week focuses on farmworker health.  Farmworker Justice has been working to protect  farmworkers' access to health care through close monitoring of the Affordable Care Act (ACA) and the impacts any changes would have for farmworkers. 

Current efforts to replace the Affordable Care Act threaten to roll back important gains in health insurance coverage achieved for farmworkers and their families. By increasing costs for young, rural, low-income individuals, the failed American Health Care Act (AHCA) would have substantially reduced access to health insurance for farmworkers and their families.

The AHCA’s provisions, including eliminating the employer mandate, modifying the eligibility for tax credits, ending Medicaid expansion, and modifying the structure of Medicaid, would have left many farmworkers with higher costs and fewer options for health insurance. Lawfully present farmworkers, especially H-2A workers, would have lost their access to affordable health insurance due to the bill’s proposed changes in immigrant eligibility for tax credits. The AHCA proposed restricting eligibility for tax credits to individuals who met the “qualified alien” definition under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA).

The ACA has provided farmworkers and their families a level of access to health insurance coverage that was previously unattainable.  While the ACA can be improved, efforts to eliminate provisions such as income-based subsidies, immigrant eligibility, Essential Health Benefits, and Medicaid expansion, will only impede access to health care to farmworker families. Farmworkers need greater, not reduced access to affordable health care.

OSHA’s New Safety Standard Excludes Farmworkers

Yesterday, 6 ½ years after proposing rules to update protections for workers from slip, trip, and fall hazards, OSHA issued a final fall-protection regulation that excludes workers on farms, ranches and dairies. Farmworker Justice is extremely disappointed that the final rule excludes agriculture from these important safeguards.
Worker injuries and deaths related to falls in agriculture are among the highest in all industries. OSHA’s explanation of the regulation repeatedly refers to the submission by Farmworker Justice as well as other worker advocates of extensive evidence to show the prevalence of falls in agriculture and that these injuries are easily preventable.

OSHA declined to include agricultural operations in the final rule, stating that the agency has not gathered and analyzed data and information necessary to support a rule. The agency had ample time – years -- to study farmworkers’ injuries and deaths resulting from falls from ladders and machinery and other hazards.
The agency did attempt to narrowly define what is covered under the agriculture exemption, stating that “if an operation performed on a farm is not an “agricultural operation” or integrally related to an agricultural operation, such as a food manufacturing or other post-harvesting operations, then the final general industry rule applies.”
Farmworker Justice will continue to help farmworkers advocate to end the history of discrimination in occupational safety standards and improve occupational safety and health in their workplaces. The full text of OSHA’s standard on “Walking-Working Surfaces and Personal Protective Equipment (Fall Protection Systems)” is available here. The comments submitted by Farmworker Justice are here

Dangerous State of Affairs: State Workers’ Comp Is Deteriorating, Says Labor Department Report

[Editor’s note: This guest blog post comes from Migrant Clinicians Network’s blog, “Clinician-to-clinician: A Forum for Health Justice.” The original blog post can be found here. Migrant Clinicians Network is a nonprofit focused on health justice for the mobile poor.]

By Amy Liebman, MPA, MA, Director of Environmental and Occupational Health, and Claire Hutkins Seda, Writer & Editor, Migrant Clinicians Network

Last week, the Labor the picture is even more complicated. They typically labor in jobs that regularly post the highest numbers of injuries each year, like farming, fisheries, industrial food processing, dairies, and construction. On top of that, they often have very low pay rates and job insecurity, due to the often temporary nature of their work. Consequently, their basic economic security is often in jeopardy, even without an injury at work. This critical segment of our country’s workforce -- the immigrants who build the roofs over our heads, harvest the vegetables on our dinner plate, and head to work to clean our office buildings while we head to bed -- is in dire need of sufficient protection considering their financial concerns and likelihood of injury. And, for some of those workers, the system doesn’t provide any protection at all.

While state-based workers& Department put out a report on state-based workers’ compensation rules. The report calls for an increased federal role in workers’ comp to ensure that injured workers are provided with adequate insurance benefits to keep them afloat while they heal -- the original intent of workers’ comp. “Recent years have seen significant changes to the workers’ compensation laws, procedures, and policies in numerous states, which have limited benefits, reduced the likelihood of successful application for workers’ compensation, and/or discouraged injured workers from applying for benefits,” the report reads, calling out denial of claims that were previously compensated and a decrease in cash benefits as examples of the weakening of workers’ comp around the country. Such changes challenge the insurance system’s effectiveness in providing a timely return of the worker to work and may diminish the ability for public health officials to understand trends in injuries in order to address ongoing hazards, through a review of workers’ claims.

For immigrant workers,rsquo; comp laws have existed in the US since 1911, the laws when first enacted didn’t cover all workers; those employed in agriculture were mostly excluded from most workers’ comp laws, leaving them out of the insurance system entirely.

Today,14 states require employers to provide agricultural workers the same workers’ compensation insurance as workers in other industries. (See MCN’s Pesticide Reporting and Workers’ Comp in Agriculture Map to see state-by-state requirements.) So, for farmworkers, who have been excluded by the state systems, federal involvement may be the only way to gain more inclusion. For those farmworkers who are covered, the increasingly weak and broken workers’ comp system is two steps forward and one step back.

We at Migrant Clinicians Network applaud the Labor Department’s report in calling out the weakening state workers’ compensation systems. We call on states across the US to both augment its rules to allow for farmworkers to benefit from workers’ comp, while simultaneously fortifying its safety net to assure that workers’ comp can effectively protect injured workers of any industry.

Learn more about workers’ comp for farmworkers, state-by-state on Migrant Clinicians Network’s Workers’ Comp and Pesticide Exposure Reporting map, here.

Read the Labor Department’s report, here.

Learn more about workers’ comp in the US today in ProPublica/NPR’s 2015 investigative reports, here.


FJ Celebrates Farmworker Health Day

Since their inception, community and migrant health centers have proven to be a vital access point to health care for farmworkers and their families. The Migrant Health Act of 1962 and Economic Opportunity Act of 1964 set in motion the network of locally driven, federally supported health centers that exist today. By having patient representation on the board of directors and partnering with other local organizations, health centers are able to evolve to meet the needs of farmworkers. As a result, health centers are often the most viable, affordable, and culturally competent providers of primary care for farmworkers.

Farmworkers face a number of barriers to care. In focus groups conducted by Farmworker Justice last year, many workers and promotores de salud discussed barriers such as transportation, language access (including availability and quality of interpretation services), cost, and clinic operating hours. They are also a highly mobile population who may need care coordination across multiple states.

Migrant health centers work to mitigate these challenges by performing enabling services such as outreach, translation, and case management. With farmworkers on their boards of directors, they are able to institute policies to respond to the needs of the community. For example, in recognition of the transportation barriers in rural communities, many migrant health centers have mobile clinics at farmworker labor camps, with some even arranging transportation to the clinic. Additionally, because most farmworkers lack health insurance and their average wages are near the federal poverty line, health centers offer care on a sliding fee scale.

In response to an FJ needs assessment survey last year, almost universally, workers, promotores de salud and community organizations cited the local health center as a critical source of primary care for farmworkers and their families when asked about health care access in their communities. Promotores reported that the health centers were very engaged with getting information and educational materials out in the community. Workers found the providers to be compassionate. However, according to data from the Bureau of Primary Health Care, in 2014, community and migrant health centers only served approximately 20% of the nation’s farmworkers and their family members.

To increase farmworker utilization of health center services, FJ participates in the AgWorker Access 2020 Campaign, led by the National Association of Community Health Centers and the National Center for Farmworker Health. The goal of the initiative is for health centers to serve 2 million farmworkers and their families by 2020. FJ provides training and technical assistance to health centers to help them address the factors that affect farmworkers’ access to health services. FJ also leverages partnerships with community-based farmworker organizations, legal services providers, Migrant and Seasonal Head Start, and other farmworker-serving organizations to strengthen relationships between the health center and the community it serves. 

FJ is proud to celebrate Health Center Week and is committed to working with health centers to continue their strong tradition of providing health care in farmworker communities.

Zika Virus and Migrants: What do clinicians need to know?

[Editor’s note: This guest blog post comes from Migrant Clinicians Network’s active blog, “Clinician-to-clinician: A Forum for Health Justice.” Migrant Clinicians Network is a nonprofit focused on health justice for the mobile poor.

Dairy Workers’ immigration status: An occupational safety hazard?

[Editor’s note: Today’s guest blog is from our colleagues at Migrant Clinicians Network, a nonprofit organization founded by migrant health clinicians that strives to improve the health care of migrants and other mobile poor populations through innovation and clinical excellence. A link to the original blog on MCN’s website can be found here.]

By Amy Liebman, MPA, MA, Migrant Clinicians Network

The American dairy farm has changed. The idyllic small family farm still gracing many milk cartons -- a few cows, rolling green hills, a red barn -- has largely been replaced by big farms with hundreds of cows milked by immigrant workers, many of whom lack the paperwork to legally work in the US. As clinicians and researchers, we wondered how this growing group of workers is faring. Our new research underscores serious health risks that these dairy workers take while they work to get milk into our cereal bowls.

As farms consolidated in the last few decades, dairy farmers, needing a new workforce, turned to immigrant workers, largely Latino. A recent survey of US dairy farms showed that about 62% of US milk is produced by immigrant workers, many of whom are unauthorized. The dairy farmers have little choice. In a Milwaukee Wisconsin Journal-Sentinel article in July entitled “Wisconsin Dairy Farmers Push for Immigration Reform,” dairy farmers voiced their struggle in finding qualified and interested workers. “If our immigrants left, we would have to dispense of everything, I guess," noted John Rosenow, a Buffalo County dairy farmer with 550 dairy cows.

Because the consolidation happened relatively recently, little data on the health and safety of dairy workers are available. At the end of 2015, we published an article in the American Journal of Industrial Medicine that gives some insight on dairy farm life, directly from the immigrants who work there. The new paper, entitled “Immigrant Dairy Workers’ Perceptions of Health and Safety on the Farm in America’s Heartland,” presents the workers’ own perspectives, garnered through five focus groups in Wisconsin on health hazards and injuries. Some of the results were predictable: farm work is dangerous, particularly for immigrants with little or no experience with large animals, and who may not be able to communicate well with farmers or supervisors because of language barriers. Cows were a major source of injury. While some injured workers received appropriate worker compensation benefits, others were instructed to deny work-relatedness. Some employers covered medical injury costs out-of-pocket, whereas others did not.

One finding was particularly noteworthy: workers identified immigration status as an occupational hazard, making them more vulnerable and putting them at further risk at the workplace. That is, lacking documentation is similar to other hazards such as lack of knowledge of workplace chemicals or insufficient health and safety training -- all of these increase the likelihood of injury on the job. While we did not set out to ask about documentation status, the workers from focus groups routinely brought it up. We conclude that this important finding in worker health and safety emphasizes the need for broader immigration reform.

Turns out, many dairy farmers agree with the need for immigration reform. The American Dairy Coalition, along with many regional dairy producer organizations, has come out strongly for comprehensive immigration reform at the federal level.

The results of this data were used to develop Migrant Clinicians Network’s bilingual, low-literacy worker health and safety program. The program, called Seguridad en las Lecherias, uses a train-the-trainer methodology to give workers basic skills and education needed to be safe on the farm. We’ve trained 850 workers thus far on nearly 70 farms and the curriculum has been disseminated throughout the US. These important steps toward improved health and safety are welcomed by workers and farmers alike, but more is needed.

As clinicians, we have a role to play in recognizing the implications of immigration status on the health of our patients. We also recognize the importance of immigration reform in improving the health of the people who are connected to us as neighbors, as providers of our food, and as fellow humans. As long as this population of workers remains vulnerable as a result of their status, all of us need to work to reduce that vulnerability.

Amy Liebman, MPA, MA, is Director of Environmental and Occupational Health at Migrant Clinicians Network, a nonprofit committed to health justice for the mobile poor. Read MCN’s active blog at

Digging Deeper: The Expanding H-2A Program in Florida & Worker's Access to Health

NPR recently aired a story, “Guest Workers, Legal Yet Not Quite Free, Pick Florida’s Oranges” that featured an H-2A worker, otherwise known as an agricultural guestworker.
In an interview at the beginning of the program, a grower of Florida citrus said that he started using H-2A workers to avoid competing for workers who were asking for a higher wage. The farm didn’t want to pay an extra nickel a box that farmworkers asked for and that a competing grower was offering. This frank statement reveals the fundamental problem with the temporary foreign worker program.
The guestworkers don’t ask for wage increases. Why? Because as the story reveals, guestworkers don’t have the freedoms that we take for granted in this country.

H-2A guestworkers may only work for the one employer that obtained a visa for them. When the job ends, they must return to their homeland. If they want to return to the U.S., they must hope that the employer will invite them back and apply for a visa. The workers have no independent ability to apply to the U.S. government for an H-2A visa. Technically, they hold a “non-immigrant” status. And the law refers to these human beings as being “imported” by employers. As if they are commodities.

In this restricted, temporary status, the workers will not usually challenge unfair or illegal conduct, or even ask for a raise. They feel lucky to have the job. And why not? Usually, the wage they earn in the U.S. is a lot higher than they would make in their own country. So they will often work to the limits of human endurance. Growers will say how “reliable” they are, but what is really going on in many cases is that these workers are under such pressure that they are extraordinarily productive.

This imbalance of power also manifests itself in the workers’ access to health care. Although all H-2A workers are covered under workers’ compensation insurance, most are reluctant to seek medical care, especially for a work-related injury or illness. In FJ’s report, No Way to Treat a Guest, Javier*, a worker in North Carolina, described how he became poisoned by pesticides while working in the tobacco fields. When he felt so sick that he could not work, he phoned a local clinic outreach worker to take him to the hospital. The hospital sent him back with a note that he could not work in tobacco. As a result, his employer sent him back to Mexico without the medical or financial assistance he was entitled to under workers’ compensation. Nine months after his injury, Javier still felt too sick to work to support his family, but could not afford specialized care to aid his recovery.

The NPR story does a good job of demonstrating the lack of economic freedom in guestworker programs. There is also a fundamental lack of political freedom. No matter how many years the guestworkers are brought back to the U.S., they never earn the right to become an immigrant or a citizen. Guestworkers don’t vote. But the employers vote. And the employers give campaign contributions. And the employer lobby Congress and the Administration to lower the required wage rates and other obligations under the H-2A program.

The H-2A program is supposed to prevent employers from undermining the wages and working conditions of U.S. farmworkers’ job terms. But the law and regulations generally don’t work. The lack of economic and political bargaining power on the part of the guestworkers is just too much to overcome.

We are a nation of immigrants, not a nation of guestworkers. The workers we need in this country – and we need farmworkers – should be given the opportunity to be immigrants and citizens. Because the majority of farmworkers are undocumented immigrants, Congress should pass immigration reform that creates such opportunities and grants farmworkers the economic and political freedoms on which this country was founded.

*Not real name

Reflecting on Rural Health Week

Last week we celebrated rural health week. Keeping our rural communities healthy is key to building a stronger America. Farmworkers and their families are essential members of our rural communities, but they are among the most underserved when it comes to health care and health insurance. The men and women who harvest the fruits and vegetables that keep us healthy deserve to be healthy themselves.

Under the Affordable Care Act, gains have been made to increase health care access for farmworkers and their families. Health centers, community-based organizations, and others have undertaken vast efforts to educate and enroll farmworkers in health insurance. Most farmworkers who are eligible to purchase health insurance in the Marketplaces qualify for financial assistance to lower the cost of premiums. Some workers are newly eligible for Medicaid in states that expanded Medicaid eligibility. For those who are not eligible, education efforts provided new linkages to health care that may not have existed before. In addition, dedicated funding through the ACA enabled health centers to expand their services in rural communities.

Yet despite these gains, we must acknowledge that barriers and challenges persist. Due to various factors, including the seasonal nature of their work, the size of their workforce, and immigration status, many farmworkers do not have employer-provided health insurance or are ineligible for health insurance in the Marketplaces. Many farmworkers, the majority of whom are foreign born, receive inaccurate or confusing information about health insurance, ACA requirements, and tax credits. Further, applying for health insurance is a complicated process that requires the assistance of a navigator or in-person assister.

Open enrollment is happening now! We encourage advocates and others who work with farmworkers to connect with health centers and others providing enrollment assistance. Farmworkers and others in rural communities deserve full access to health care and health insurance. Farmworker Justice developed materials for farmworker families to help them understand the ACA and connect them to in-person assistance in their area. These materials can be downloaded from our website.  


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