Health & Occupational Safety

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idyllic small family farm still gracing many milk cartons -- a few cows, rolling green hills, a red barn -- has largely been replaced by big farms with hundreds of cows milked by immigrant workers, many of whom lack the paperwork to legally work in the US.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.  

Supreme Court Ruling on Affordable Care Act Helps Keep Farmworkers Covered

Farmworker Justice applauds the Supreme Court's decision to uphold the Affordable Care Act's (ACA) provision to provide subsidies (in the form of tax credits) to consumers who bought health insurance through the federally-facilitated health insurance marketplaces ( The subsidies are essential to ensure that farmworkers and their families have access to affordable health insurance. The Court's decision ensures that the millions of people can stay covered on their health insurance plans without fear that their premiums will suddenly become unaffordable.

Nearly 6 million people nationwide are enrolled in health insurance through the marketplaces. Among low-income adults, there was a 6% decrease in the uninsured rate in 2014. For Hispanic individuals, there was approximately a 5% decrease in the uninsured rate. While we do not have data on the number of farmworkers who enrolled in health insurance under the ACA, many farmworkers who did enroll were first-time enrollees who received substantial subsidies to lower the cost of health insurance.

Currently, 34 states, including many states with significant farmworker populations (such as North Carolina, Florida, and Texas) use The Court's ruling ensures that farmworkers who live and work in these states will continue to have opportunities to enroll in affordable, comprehensive health insurance. Farmworker Justice will work with our partners across the country to provide information on the ACA to further facilitate farmworker enrollment in health insurance. 

Study Estimates that 77% of Agricultural Injuries are Unreported

A recent study by health economists at the University of California at Davis and Old Dominion University estimates that over three quarters of all agricultural nonfatal injuries and illnesses are not included in official counts kept by federal agencies. The study, which was published in the April edition of the Annals of Epidemiology, used several sources of data to estimate the undercounting and considered various factors that affect whether or not an injury or illness is ever reported.

The official count of agricultural injuries and illnesses in 2011 on both crop and animal farms, reported by the Bureau of Labor Statistics, is 32,100; however, this number does not include injuries or illnesses sustained by workers on farms with less than 11 employees, by contracted workers, or family members. It also does not account for failures to report injuries. When conservative adjustments are made, the estimated number of job-related injuries and illnesses experienced by agricultural workers in 2011 rises to 143,436.

Agricultural injuries and illnesses take many forms from falls, cuts, and lifting injuries to chemical exposures, vehicle and machinery accidents, and even chronic pain associated with repetitive movement and ergonomic issues. These conditions disproportionately affect migrant and seasonal farmworkers and, with this study, we now know that these injuries are even more widespread than previously reported.

Lack of reporting and undercounting of injuries and illnesses have serious consequences for farmworkers, many of whom do not receive information on how to prevent, avoid, and care for injuries or how to report violations of their labor rights. Agriculture, as an industry, is dangerous. The most affected individuals belong to a workforce that is less able to advocate for its basic rights. This information is not new, but as we are better able to measure how dangerous agricultural occupations are, we can use this data to implement safety measures and better support the people who experience the risks associated with work in agriculture.

Accurate injury and illness reporting will justify stronger policy to protect this valuable workforce, including increasing educational programs to inform farmworkers of the risks to their health, help them prevent injuries, and to exercise the basic rights and protections afforded to all workers in the United States. Comprehensive immigration reform will also support farmworkers and decrease agricultural injury by increasing access to information and removing barriers to health care.

Reversing America’s Declining Health Trend Means Focusing in Equity

For the first time in decades, the current generation isn’t as healthy as the one that came before.” The theme for day five of National Public Health Week is “Be the Healthiest Nation in One Generation” and is dedicated to turning around the declining trend in health faced by Americans today. To address this trend, it’s important that we understand the barriers to good health faced by all people in the United States. At Farmworker Justice, we spend a lot of time contemplating migration as a social determinant of health. Specifically, we discuss the roadblocks that affect good health and quality of life and we think about ways to lift those roadblocks, either through advocating for policy change or through health promotion and education projects.

In terms of farmworkers, migration from their home to the U.S. has a lot to do with their health. Just a few factors related to migration that affect farmworkers include poverty, language, discrimination, and national policies.

Most farmworkers live at or below the poverty line. Health outcomes of people who live near the poverty line are worse than for those who enjoy higher incomes.
Eighty-one percent of farmworkers speak Spanish but immediately after arriving in the U.S. they need to navigate everything from grocery stores, public schools, housing, and health clinics almost entirely in English.
• Discrimination, both overt acts of discrimination and microagressions (every day, more subtle forms of discrimination), is associated with increased anxiety, anger, depression, and stress levels.
• Policy can be discriminatory when it is does not provide protections to workers equitably across professions. For example, many states do not require agricultural employers to provide workers’ compensation insurance coverage for farmworkers, even though agriculture is ranked among the most dangerous occupations by the U.S. Department of Labor.
• Policies that don’t seem to be about health, like immigration policy, can actually have a great impact on the health and wellbeing of our community members. For example, children who hear about deportations may constantly fear the separation of their families and people who cannot obtain driver’s licenses may avoid driving to a clinic.

Not only do poverty, language barriers, discrimination, and policy serve as enormous sources of stress, but they also stand in the way of accessing and receiving appropriate medical and mental health services. In addition, sixty-four percent of farmworkers are uninsured, so even when they do seek care, paying for it presents another barrier.

To reverse the decline in the nation’s health outcomes, it is important to address the barriers, social inequalities, and injustices that contribute to the decline. We must also recognize that the health of each individual is affected by the overall health of our communities so working toward better health outcomes for the entire community will create better health for each individual.

Farmworkers and our Food Safety System

The CDC estimates that each year roughly 1 in 6 Americans gets sick, 128,000 are hospitalized, and 3,000 die of foodborne illnesses. We’ve all seen the frightening consequences from fruits and vegetables contaminated with salmonella or listeria. Eating safe, healthy food, today's theme of National Public Health Week, is a basic building block of public health. While most conversations about this topic revolve around responding to outbreaks or creating more rigorous standards and surveillance by government agencies, few consider the important role of farmworkers in preventing foodborne illnesses.

Food safety advocates have long recognized that the working conditions and training of farmworkers can significantly affect food safety: overworked and underpaid farmworkers in the field are typically not encouraged to look out for safety concerns. If employers don't provide sanitary facilities, or fail to provide the necessary training or economic incentives to stop production when unsafe conditions exist, important opportunities to improve food safety are lost. 

Farmworker Justice is a co-founder of a unique collaboration between farmworker, environmental and consumer advocates, retailers, and farmers that aims to promote food safety and improve working conditions in the produce industry. The Equitable Food Initiative (EFI) has developed a set of food safety, labor, and pesticide standards and a training program to help farmworkers and farm owners and their managers work together to implement the standards. 

EFI's food safety standards recognize that farmworkers are often the first line of defense against contaminated food. Under the EFI system, workers receive training to recognize food safety risks and are encouraged to report unsafe conditions, improper practices or procedures in the field to their supervisor. It’s a common sense approach to food safety that benefits workers, growers, retailers and consumers: fresh fruits and vegetables grown and harvested in ways that respect workers can help reduce the potential for transmission of foodborne illness.

National Public Health Week: Getting Ahead with Preventative Health Care

Day three of National Public Health Week is entitled “Get Out Ahead!” and is dedicated to prevention as a national priority. Community and migrant health centers across the United States serve the preventative and primary health care needs of many of the farmworkers who plant, tend, and harvest the nation’s crops. Farmworkers and their families encounter numerous barriers to accessing health care such as cost, transportation, language, and lack of sick leave, to name a few. Outreach is a critical component of health care delivery to farmworker communities. I spent several years as a farmworker health outreach worker in rural North Carolina. This personal experience working in farmworker health in a small community provides insight to health problems faced by farmworkers and the barriers they regularly face when seeking health care.

Let’s first start with some quick farmworker health facts. Agricultural work is low paying, physically demanding work. The Bureau of Labor Statistics ranked agriculture as the third most dangerous job in 2012. Many farmworker families live at or below the poverty level and approximately 64% are uninsured. Cancer, heart disease, stroke, and diabetes are among the top five causes of death for Latinos in the U.S. For farmworkers, specifically, many of whom are Latino, a recent study showed an elevated prevalence of anemia and obesity and stunting in children of farmworker families. The burden of these conditions can be lessened or prevented under the regular care of a physician. Lack of insurance limits the options that farmworkers have when they seek health care and it is sometimes a barrier to receiving care at all. Many turn to community and migrant health centers to receive preventative care where they are able to pay for health care on a sliding-fee scale based on their income. Outreach workers are a valuable part of the health care team at these health centers.

As an outreach worker, the farmworkers I served worked in the Christmas tree fields nine months of the year. Many traveled from Mexico year after year to do this work, leaving behind their homes and families to live with other farmworkers in old houses, trailers, or barracks that were provided by the growers that hired them.

My work entailed visiting farmworkers in their homes in the evenings after work, collecting their personal and contact information, asking questions about their health, and screening for diabetes, high blood pressure, and HIV. They would usually be cleaning up from work and taking turns in the kitchen so many of these conversations happened while they cooked dinner and made lunch for work the next day. I let them know their options for accessing health care in their community and explained the process for making and paying for appointments. During the day, I coordinated these appointments, making calls to farmworkers, clinics, and specialists. I drove farmworkers to appointments and provided Spanish-English interpretation. I learned about their home towns. I heard border crossing stories. I knew when their kids in Mexico were getting in trouble at school. Working in this capacity allowed me to spend the time necessary to gain the trust of farmworkers within our community. I used this insight to help doctors, nurses, dentists, and clinic administrators better understand the conditions that affect farmworkers’ health and adjust treatment plans to best fit the realities they face.

The outreach workers at community and migrant health centers connect farmworkers to important preventative health care services through education, case management, and building trust within the community. The work, while challenging, is extremely fulfilling. We recognize that regardless of where you live, everyone has a right to be healthy. Our nation’s farmworkers, who harvest the fruits and vegetables essential to our health, deserve access to quality health care.

National Public Health Week: Be Healthy from the Start

April 7th begins the 2014 National Public Health Week! Today’s theme, “Be healthy from the start,” is especially important when bringing awareness to the current state of farmworker health in this country. Today, we focus on farmworker children and access to health care.

Individuals with health insurance are more likely to seek medical care. In the U.S., a staggering number of farmworker children do not have health insurance. Data on farmworkers and their families are hard to collect because of the seasonal and migratory nature of farm work. For this reason, we focus on statistics that describe rural Latinos in the U.S.:

• 31% of rural Latino children are uninsured, compared to 15% of African-American children and 18% of non-Hispanic white children.
• Only 33% of first-generation immigrant children are continuously insured.
• Rural Latino children whose parents are immigrants are even more likely to lack health insurance, even though the majority of them qualify for enrollment in Medicaid or the Child Health Insurance program (CHIP).

Cancer, heart disease, stroke, and diabetes are among the top five causes of death for Latinos in the U.S. The burden of these conditions can be lessened or prevented under the regular care of a physician. Children with health insurance are more likely to have a regular source of health care than children without health insurance. Children who receive regular medical care may grow into adults that value preventative care.

Farmworker Justice is working to diminish the disparity in health care coverage experienced by rural Latino children in the U.S. In the coming weeks, we will be rolling out a program called Conexiones: Connecting Rural Latino Families to Medicaid and CHIP. Four community-based organizations in Florida, North Carolina, California, and Arizona will work with Farmworker Justice to train promotores de salud (lay health workers) to conduct outreach in their communities. They will educate their peers on the eligibility requirements for enrollment in Medicaid and CHIP and help to connect them to state and local resources. In two years, the promotores de salud are expected to reach over 14,000 rural Latinos with information on Medicaid and CHIP, which will increase health care coverage of children in their communities substantially.

This program utilizes the promotores de salud model because these community health workers are extremely effective in engaging in outreach in their communities, especially with hard-to-reach populations. Often sharing the same language and cultural background as those receiving their outreach efforts, they know best where to find their fellow community members and how to effectively deliver important messages about health and in this case, access to health care.

Taking a Closer Look at Farmworkers and Cancer

 According to a 2010 poll, cancer is the disease most feared by American adults. And rightfully so, as the National Cancer Institute’s surveillance program reported that same year that over 13 million Americans were living with cancer. Farmworkers number over two million in the U.S. and are predominantly of Latino or Hispanic ethnicity. Even though cancer incidence and death rates for Latinos are lower than for non-Hispanic whites and, in fact, are declining, U.S. Latinos have higher rates of cancer caused by infections, such as cancer of the stomach, liver, uterine cervix, and gallbladder. Furthermore, while Latina women in the U.S. have lower rates of breast cancer than non-Hispanic women, they actually have a 20% greater risk of dying from the disease, making breast cancer the leading cause of cancer mortality among Latina women.

Farmworkers are not only at increased risk for developing cancers caused by infections and cancer mortality, they also experience higher exposures to cancer-causing chemicals through the pesticides they apply to crops and come into contact with during planting, weeding, pruning, and harvesting. Making the link from pesticide exposure to cancer diagnosis is difficult, as the time between exposure and diagnosis may be years; however, research is beginning to show an association. For example, a 2012 study of Canadian women who had been exposed to cancer-causing and hormone-altering chemicals while on the job found that women who worked in agriculture had a significantly higher risk of breast cancer later in life.

Farmworkers in the U.S. experience conditions both on and off the job that affect their health. Several underlying factors contribute to this, including immigration status, language, family separation, and poverty. Seventy percent of farmworkers are migrants from Mexico who speak Spanish or an indigenous language and at least 50% lack authorized immigration status. Half are under the age of 31 and most are unaccompanied by any family members (61%). Many farmworkers report that poverty and lack of opportunity in their home country was their main motivation for migrating.

These underlying factors are reinforced by policy which influences social norms and both govern the communities where farmworkers settle. Ultimately, restrictive immigration policies decrease farmworkers’ ability to speak up about dangers on the job, increase exposure to dangers, and inhibit their ability to seek medical treatment, either for pesticide exposures or to prevent infections that cause cancers.

National and state-level policies around immigration and the rights of immigrants contribute to disparities in cancer rates. Not only do they put more farmworkers in harm’s way, they create an environment in which discrimination is normalized and unnoticed, increasing feelings of fear, stress, negative coping behaviors, and affecting daily living and working conditions. They create an environment in which the odds are stacked against escaping these conditions.

When we think about the underlying factors affecting our health we begin to question what we’ve always been told – that opportunity is distributed equally. Motivation, persistence, and determination, which are prerequisites for making the journey from Latin America to the U.S., might not be enough to rise above and break through the strong and ever present external forces that hold us firmly within our socio-economic status and directly affect our quality of life and health.


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