Capt. Evangelina Montoya, RN, MSN, is reading aloud from a report on migrant farm workers. “‘We work from sunrise to sunset,’” she recites, “‘and my body gets so tired it’s hard to walk. My uncle has to park the truck so far away, and I get so cold and tired when I walk back to the truck.’”
This experience is all too familiar to Montoya, who grew up as the daughter of migrant farm workers in Visalia, Calif. “I can put my face on this story,” she says. “For me it isn’t just statistics—it was a fact of life.”
When Montoya started attending community college, she realized that she wanted to go into the health care field. “I chose nursing because it reflected my values,” she explains. Her interest in providing health care to an underserved population in a rural community, along with her desire to travel, drew Montoya to public health nursing. Now a commissioned officer in the U.S. Public Health Service, she is a public health analyst for the federal Division of Community and Migrant Health, where she helps develop health care policies affecting migrant workers.
Another former migrant worker who is dedicating herself to improving health conditions in migrant communities is Aurora Hernandez. Growing up in Texas, Minnesota and Wisconsin, Hernandez worked the fields while other kids rode their bikes and went to Disneyland. Every year, her mother took her to a migrant health clinic for a checkup. When she was 12, Hernandez was examined by a nurse—an experience that made a lasting impression on her young mind.
“The nurse could probably tell that I was unhappy,” Hernandez recalls. “I wasn’t looking up and I didn’t talk much. She was concerned about me, and I noticed how nice she was. She was very sincere and kind.”
When the young girl asked the woman what she did, she replied that she was a nurse. “That was my first experience meeting a nurse and seeing how their work involves helping people,” says Hernandez. “I realized that [as a nurse] I could have a good job, be able to talk with kids and families and spend my day inside a building! From that day on, I wanted to be a nurse and work with migrant kids.” Hernandez is now a nursing student at Georgetown University in Washington, D.C., and the first Hispanic president of the National Student Nurses’ Association.
Migrant farm workers are the people who pick the fruits and vegetables that you and your family eat every day. There are three to five million of them in the United States and their average income is less than $7,500 a year. Eighty percent of these migrant farm workers are Hispanic, and two thirds of them are under 35 years of age. Sixty-six percent of migrant worker parents have their children with them as they work.
The migrant worker community is divided into three “streams.” The West Coast stream stretches from California to the Pacific Northwest; the Midwest stream starts in Texas and extends north, while the East Coast stream reaches from Florida to Vermont and New Hampshire.
A migratory lifestyle and harsh working conditions create a myriad of health problems for these workers. “They have more complex health problems than those of the general population,” Montoya notes. “They suffer more frequently from infectious disease and they have more clinic visits for diabetes. Contact dermatitis is also common because of the exposure to pesticides.” Other common ailments affecting migrant workers include cancer, hypertension and asthma.
Many of these health problems stem from poor nutrition. “Migrant farm workers have extremely low incomes, and they work six days a week, 10 to 12 hours a day,” explains Hernandez. “When things are really terrible—when the weather’s bad and the crops aren’t growing well—the result is malnutrition. People working 10 to 12 hours every day in 95-degree weather have tremendous nutrition needs.”
The health of migrant workers’ children is another area of concern. These children often suffer from Vitamin A deficiencies or ear infections that can lead to deafness if left untreated. Pesticide exposure is another serious health issue. One recent study revealed that 48% of migrant children had worked in fields when the plants were wet with pesticides and 36% had been sprayed either directly or indirectly by pesticide drifts. Thirty-four percent of children’s homes had been sprayed in the process of crop-dusting the fields.
“As the planes sprayed the fields, you could feel the drifts,” remembers Montoya. Hernandez has similar memories. “Every morning, the crops were sprayed,” she relates. “[It mixed with the dew] and when it dried, the pesticide residue would be on your clothes and your skin. It looked like a white film.”
Such exposure is particularly dangerous for children because their higher metabolic rates and lower body weights make them more susceptible to the toxic effects of pesticides than adults.
Some migrant worker health disparities have a devastating effect on both parents and their children. “There is a very high rate of depression in both mothers and fathers in migrant families for a variety of reasons,” says Mary Lou de Leon Siantz, RN, PhD, FAAN, who teaches at Georgetown University and is the current president of the National Association of Hispanic Nurses. “Depressed parents are less able to interact and communicate with their babies, and that places a child who’s already at a substantial risk for health problems at an even greater risk.”
Siantz has received funding from the National Institute for Nursing Research to study the prevention of developmental delays in Mexican migrant infants. She is also actively involved in getting migrant babies prepared for school in the Migrant Head Start program and is working with the University of Washington to develop a culturally and linguistically sensitive intervention program for Spanish-speaking migrant workers.
Still another factor that contributes to increased health risks for migrant workers is substandard housing. “Whatever the farmer [whose fields you are working in] provides is where you live,” says Hernandez. “Our family lived in houses that had been condemned.”
Nurses who work in migrant communities can attest to the health problems poor housing can cause. “We see increases in infectious diseases, gastrointestinal disorders and emotional distress in people exposed to those living conditions,” Hernandez explains. There are increased risks of accidental injury as well, she adds. “People can fall through holes in the floor. At one home I lived in, I fell into a well that was covered up by grass and dirt.”
Even though they face disproportionate health risks, most migrant farm workers don’t have the peace of mind of health insurance. Because they are always on the move, they rarely reside in one place long enough to qualify for insurance. As a result, routine medical exams account for only 1.4% of all visits to the Division of Community and Migrant Health’s clinics—39% below the national average.
“By the time they show up in the ER or at the clinic, their health problems have become very severe, because [nurses] don’t see these patients until they’re too sick to work,” says Montoya.
Then there’s the issue of lack of access to health care. Migrant families tend to work in regions that are even more remote than typical rural communities, and these areas often lack clinics and medical professionals.
The Division of Community and Migrant Health is attempting to address these problems through a national nursing voucher program that is instituted in regions where migrants work for only a few months and then move on. Under this program, migrant workers can receive vouchers to bring to participating clinics to “buy” health care services. The program also allows nurse practitioners to provide primary health care, and RNs can refer workers to a physician or another nurse for advanced medical care. Currently, there are 21 such voucher programs providing health care to migrant workers in the United States, serving some 56,000 patients per year.
“Nursing voucher programs are an area where nurses can really take the lead in filling gaps in migrant workers’ access to medical care,” says Gloria Torres, RN, MS, assistant clinical director of Community Health Partnership (CHP) in Aurora, Ill., an organization that serves migrant farm workers exclusively. Another nurse who grew up in a migrant worker family, Torres administers a nursing voucher model that is used at six CHP sites in Illinois.
Imagine trying to comprehend health care information from a doctor who speaks only Swahili and you’ll understand why language differences are another major barrier to providing effective health care to migrant farm workers. “My parents spoke Spanish at home, so I didn’t learn English until I started school,” says Montoya. Hernandez also has experience with the language barrier: “When I was a young child of 11 or 12, I went with my parents to the doctor to translate for them.”
Cultural barriers may have an even stronger effect on health care providers’ ability to treat migrant workers. “My father had hypertension and diabetes,” Hernandez recalls. “He would say ‘yes, yes’ at the clinic, but at home he would not do what they told him to. I came to realize that he didn’t trust them, because they didn’t understand his culture. When you’re discussing food with a migrant worker who is diabetic, you need to understand that they eat tortillas, beans and rice because they work 10 to 12 hours a day, and they need food that will help them do all that work.”
These cultural and linguistic competency issues help explain why the field of migrant worker health care urgently needs more Hispanic nurses. Sara Erlach, a retired nurse who received a Lifetime Achievement Award from the National Association of Hispanic Nurses last year for her pioneering work in migrant worker health care, emphasizes that “[minority nurses] are in demand everywhere. Only 2% of the RN population is Hispanic.”
The demand for nurses who speak the language and who are familiar with (or are willing to learn about) the needs of migrant farm worker communities is especially great. Nurses need these qualifications to earn the trust of Hispanic patients, Hernandez explains. “When my father finally met a nurse who spoke his language and came from his background, that’s when [the health care advice] really clicked,” she says. “Everything that nurse said was like the Bible to him. He felt that she understood his life and he believed everything she told him.”
There are many opportunities available for nurses who want to enter the field of migrant worker health care. “If you’re working at a migrant health clinic, you can work as an LVN as well and do some of the technical aspects that are done in traditional clinics,” says Siantz. Other opportunities include making home visits in migrant communities, teaching health awareness, developing public programs and creating public health announcements for Spanish-language radio.
Research on migrant health issues is another important career path. “If we had more [nurses] interested in research, we could develop better policies and have more advocates and clinicians,” says Hernandez.
Some of the most rewarding career opportunities for nurses in migrant health care are with the federal government or other nonprofit national organizations, such as the National Center for Farmworker Health, the Migrant Clinicians Network, the Pan American Health Organization and the U.S. Department of Health and Human Services’ Office of Minority Health (OMH). To find migrant worker clinics that may be looking for nurses, contact the OMH and ask for information about clinics in your region of interest (see “Resources”).
When asked what qualities a nurse needs to become involved in migrant worker health care, Siantz lists only three things: “Good communication skills, an understanding of the culture and a good heart.”