Newsletter: May 2002
Ann Miles, Contributing Editor
When I began editing this column three years ago, I urged one of my undergraduate students to write an article about his experiences as an outreach worker in a rural clinic serving migrant farmworkers. Even though they live and work quite literally in our “backyards,” the health concerns and living conditions of migrant farmworkers often resemble those in the “developing” world. It is not surprising then that the models used to provide services to migrant workers mimic those found in international public health projects. My student, Dylan Clark, does nothing halfway, and by the time he finished his captivating but way-too-long article, the length of the section columns in AN literally had been cut in half. All thoughts of printing his article in its entirety here had to be abandoned. What follows is a brief description of Dylan’s experiences.
Experience in Migrant Health Care
By Dylan J Clark (Tulane U)
When I began working for the Migrant Outreach Program at InterCare Community Health Network in May of 2000, I had no idea what the job involved or what direction the position might take me. Like most students facing the end of winter semester, I was looking toward the months ahead in keen anticipation of achieving steady summer work. I was not expecting to find a temporary position that would both keep me working (thus making ends meet) and provide a rewarding experience that would help me to grow as a student of anthropology as well as a person. Sometimes, however, it seems that the right combination of factors seems to fall into place at the most unexpected times.
As a recent Anthropology graduate of Western Michigan University, I jumped at the opportunity for a part-time position in the field of rural and community health. Armed with only an introductory knowledge of medical anthropology and no experience in the field of health care at all, I saw the opportunity to work with the migrant and seasonal farm worker community as a chance to utilize both my anthropological and Spanish language skills. I was not to be let down.
I have always felt most comfortable when a little uncomfortable, pursuing interests in what is, for me, new territory. I had read little about farmworkers, in fact my perspective on the migrant situation had largely developed from the other side of the border through conversations I shared with former migrants while living in Querétaro, Mexico.
As a result, I found myself on unfamiliar terrain at the outset of the migrant season, jumping into the deep in end of the outreach pool. I would later realize, that the ever-changing nature of the migrant context itself, along with the myriad of institutional challenges that Michigan migrants face, make direct participation a necessary condition of understanding it. I needed to delve into outreach, becoming actively involved (and at times thoroughly frustrated), to truly grasp the effects of the socio-political barriers to health in migrant communities, as well as the biomedical community's responses to these barriers-both effective in terms of individual cases and ultimately limited in terms of the large-scale structural changes necessary to positively impact migrant health .
InterCare and its Special Programs
InterCare Community Health Network is an agency comprised of six primary
care medical clinics and four dental clinics, each located in rural communities
or low-income areas within larger cities. Although the focus of the agency
extends beyond the migrant population to encompass a larger "community,"
the clinics continue to be directed toward providing comprehensive primary
care to migrant workers and their families, specifically promoting its bilingual
services and Sliding Fee Discount Program.
InterCare and the services that the agency provides center upon a shared philosophy that all people have the right to equal access to quality health care. The implicit assumption is that some people experience significant barriers in accessing health care, whether institutional, political, cultural, economic, social, linguistic, or otherwise. What struck me initially was the parallel between Intercare's philosophy and one of the key concepts from an introductory course in critical medical anthropology, specifically the notion that there are a variety of non-physiological, (I will call them "institutional" for lack of a more universal term, but they could be social, political, cultural, etc.) factors that impede people from achieving sustainable health and wellness.
Special Programs at InterCare is a multi-faceted component of the agency specifically devoted to addressing these types of barriers. It does this by initiating grant-funded programs targeting the problems directly affecting the health status of migrant and seasonal farmworker communities, problems that are currently considered top priority based on national, state, and local statistics. InterCare's Special Programs are made up of Maternal and Infant Support Services, the Breast and Cervical Cancer Control Program, and the Migrant Outreach Program.
Under the auspices of the Special Programs Department, the Migrant Outreach Program at InterCare acts as the clinics' main communicative link with their clientele, representing and translating both linguistically and culturally the interests of the clinic and the larger agency to the patients and, conversely, the needs of the patients to the clinics. This has placed the Migrant Outreach Program in a complicated position in which it must play multiple roles as it attempts to confront and negotiate the various factors that influence health in the farm worker community. The Migrant Outreach Program (including staff, services, and educational resources) is funded primarily by state grants aimed at three main focus areas, namely the Camp Health Aid Program (Promotoras de Salud), outreach nurses for migrant camp visits and local migrant education programs, and childhood immunizations. Outreach staff in each of these areas concentrate efforts to break down barriers by providing special services, educational resources, and basic health care information to migrant farmworkers and their families.
The Changing Faces of Migrant Outreach
Rarely specifically defined, outreach carries with it many faces both in
and out of the clinical setting. Outreach staff, for example, may find themselves
involved in many and diverse roles including translator, advocate, public
relations expert, social worker, health care advisor, emergency transporter,
and/or educator, while simultaneously assisting with immunizations, patient
compliance issues, and basic health screenings on any given day of the harvest
season. Outreach has had to develop each of these varying roles, largely
as a means of negotiating effective solutions in the short-term to a multitude
of challenges over which it has very little control in the long-term. Attempting
to develop creative and appropriate strategies to impact each of these areas,
most of which change annually, is ultimately outreach's responsibility,
at times both frustrating and exhilarating.
Complicating the matter is the fact that outreach is based on the needs of a constantly fluctuating community. Outreach staff must be able to draw from a mixed bag of responses and resources to address changing situations, while simultaneously justifying the program's existence by increasing awareness in the biomedical establishment. The programs and staff must be able to adapt to each season's challenges, drawing from past experience and knowledge.
As I became more involved in outreach and began to re-process the theoretical information I had acquired during my undergraduate studies amidst the backdrop of practice, I was astounded by just how highly politicized the inclusion of these types of services into the health care system really is. Just examining briefly the ways in which these programs are funded and the resources distributed, one can see that there is a constant struggle to justify the legitimacy of such programs to the bureaucratic institutions within which they operate. I realized that an outreach program's success or failure really must be measured in how effective a balance is maintained between navigating the bureaucratic institutions at both the state and federal levels, and actually dispensing services and information to individual patients.
The mainly seasonal outreach staff is a conglomerate team comprised of outreach coordinators and assistants, RNs, LPNs, biomedical students, Spanish language students, former missionaries, migrant farm workers, and in this case a student of anthropology. While on the surface this diversity appears a bit daunting, particularly in terms of inter-departmental relationships and communication, it actually stands as a powerful asset whereby the team's ability to inform, educate, and develop a working relationship with its target community is greatly enhanced by the sheer multi-vocality of perspectives.
The constant requirement of outreach staff to play multiple roles in so many different types of interactions and settings initiates a continuous positioning and repositioning with respect to the provider-patient-clinic relationship, which inevitably leads to translation at many levels. This translation is not simply a matter of language, but also of social relationships and positions within those relationships that further enhance the empowerment (or disempowerment) of patients who are repeatedly engaged with illness and health, health care providers, and biomedical models.
For example, from the first moments that providers and patients come into contact in the clinical setting, they immediately position themselves in relation to one another. Here they are actively engaged subjects in an interactive experience, involved in a relationship of power. While in most cases, the provider is usually at his or her most dominant and the patient at his or her most vulnerable, the situation may be either compounded or totally reversed when the concepts of illness and health are inserted into the picture, additional social beings become engaged, and/or the social, political, cultural, or economic context shifts.
In addition, cultural translation also stands as a key component of rural health care in southwest Michigan where many providers and patients must connect across cultures, at times with the help of an interpreter, to find common ground. This is certainly a major component of outreach and may be the most difficult step, as all parties involved have notions of each other that are historically constructed and often emotionally charged. Fear, suspicion, and distrust rooted in intercultural experiences with discrimination, exploitation, and ethnocentrism may also stand as significant, though unacknowledged, barriers to health care.
What I intend to do here is share a particular experience I had working with a migrant family who came to Michigan during the summer of 2000 from the state of Querétaro, Mexico. I chose this experience because it has always stood out in my mind as representative of the kinds of challenges migrant families face in pursuit of the basic health care services that those of us in the dominant culture have come to enjoy as staples of our participation in American society. It also demonstrates some of the multiple roles outreach staff play during the season in developing responses, some effective and others limited, to these challenges.
The elements making up the sum of this experience added another dimension to my perspectives, borne largely out of a critical approach to medical anthropology as I conceptualized it in the classroom. I began to see the theoretical issues surrounding the multiple institutional barriers to sustainable health that some marginalized societies face leap off textbook pages and out of classroom discussion and into a real-life setting in which I found myself actively engaged. I came away from the experience making several connections, one of which was the link between federal, state, and local legislation regarding Medicaid and the appropriation of certain economic resources and this family's inability to participate in the mainstream health care system. Moreover, I came to understand more completely the limits within which any medical outreach program must operate. These limitations, in combination with the delicate issues of positioning within a larger social, political, and economic framework, present major constraints to the promotion of long-term, sustainable health in the seasonal migrant community. Ultimately, whether readers filter out these points or perhaps draw other conclusions, I hope that the experiences of "Edgar" and "María," as I have chosen to identify them here, raise critical questions and further discussion of potential strategies for anthropologists and other professionals working in the field of migrant and rural health care.
I would also like to make the point that these professionals, whether they have an anthropological background or not, have probably observed these issues emerging again and again in many different cases. I do not wish to suggest that anthropologists as such have any broader ability to see these issues for what they are than anyone else working in this field. I do believe, however, that people with experience in anthropology have developed the kinds of critical perspectives that are strong assets to any outreach team. Students of anthropology are likely to see these institutional factors as primary (not secondary, non-essential, or irrelevant) influences in the health and illness of marginalized groups. I hope my experience encourages other students of anthropology to take the initiative to become involved at some level in community health care.
Michigan's Migrants: Edgar and María's Experience
It was late in the 2000 harvest season when Edgar and his wife, María, set
out from the rural town of Tequisquiapan in the state of Querétaro, Mexico
en route to Berrien Center, Michigan. It was only the third time that they
had crossed the Rio Grande in search of work in the United States, each
time finding roughly nine months of harvests in both the apple orchards
of southwest Michigan and the citrus fruits of the west coast of Florida.
Despite the late start, Edgar and María were optimistic. This year they
were traveling with a contractor, "Hector," whom they knew well and trusted
not only to transport them safely across the border, but also to connect
them with patrones, or growers, who would supply plenty of work and ask
no questions. They even invited María's sister along who, as a teenager,
was now old enough and strong enough to earn additional cash and provide
welcome companionship. This year Edgar and María were not alone.
According to University of Michigan researcher, Daniel Rothenberg, recent estimates place the number of migrant farmworkers in the U.S., including their families, as well over 1 million (1998:6). Of these families, the vast majority are ethnically and culturally Hispanic-as is the case in Michigan where Latino migrant workers may originally stem from the U.S., Central and South America, or the Caribbean. According to recent national statistics, over 90% of all Hispanic farmworkers are from Mexico (Rothenberg 1998:7). As is the case with Edgar and María, many of these immigrants also identify themselves as indígenas, having some connection (either culturally, linguistically, or regionally) to indigenous groups in rural Mexico.
In the state of Michigan there are at least 38 different crops that require migrant labor, and these crops alone have a seasonal, statewide production value of 2.1 billion dollars (Michigan Department of Agriculture Website). The National Council for Farmworker Health estimates that in the year 2000 roughly 45,000 migrant farmworkers literally harvested and processed this profit for growers and the state while living in labor camp housing whose "official" state-wide capacity was only 25,000 (Michigan Department of Agriculture). While the statistics have yet to be totaled for 2001, there is little doubt that despite a wet start to the year and a delay in some production, a comparable number of migrant workers once again returned to Michigan. The most current estimate for a national average annual wage is roughly $6,500 per worker (Rothenberg 1998:6).
Edgar and María had no way of knowing before their journey began that in 2000 a severe fire blight, in combination with heavy rainfall during the early summer months, had drastically effected apple crops in southwest Michigan. Many growers reduced, changed, or plowed over their fields, and as a result, the amount of work available and the length of the season was limited. While Hector was able to secure employment for the family through a grower who "only hired Mexicans," neither Edgar, María, nor María's sister had the opportunity to work a full week picking in the orchards. Their initial optimism was further tempered when Edgar suddenly began experiencing intense pain and discomfort in his lower abdomen.
It was only after Edgar had worked three twelve-hour days picking and hauling apples that his pain became unbearable enough that he considered it vale la pena (worthwhile) to lose a day's wage and ask Hector for a ride to the nearest clinic. It's rare to find a contractor who is willing to attend to the personal needs of his crew, but Hector had a reputation for being particularly compassionate, especially to fellow Mexicans. He had also grown close to Edgar and María and was thus eager to extend a helping hand. Hector, Edgar and María piled into his pick-up truck and drove the short distance to the local health center.
At the height of the migrant season, and even into the later stages of the apple harvest, InterCare's Eau Claire Health Center is almost always packed with patients. With a limited number of staff, an extremely popular physician, and, of course, a large number of migrant and seasonal farmworkers living and working in the area, obtaining an urgent appointment on short notice can seem as difficult as bringing a space shuttle back to Earth. There are very few windows of opportunity available to squeeze in amongst months of scheduled appointments and limited walk-in hours. There are almost always long hours of waiting in the crowded anteroom prior to being seen by a provider.
Edgar's appearance at the clinic on one such busy day resulted in a sequence of events that broke from the usual routine. The staff had to consider two important factors. On the one hand, Edgar was experiencing intense abdominal pain, an urgent problem by most standards. Although the wait was considerable, it was obvious that he needed to see a physician in a relatively timely manner, and InterCare's policy insures that all patients that present receive care. Complicating the matter, however, was the fact that Edgar had no documentation, no social security number, no visa, and hence no access to Medicaid or any form of health insurance. While this makes no difference at InterCare, it places an expensive emergency room visit and ambulance transport for anything less than potential death completely out of the question. The staff at Eau Claire had no recourse but to refer the patient to another InterCare Center that had fewer patients scheduled for that day. The nearest site turned out to be roughly 40 miles away.
Things had slowed considerably in days prior as many of the migrant workers in southwest Michigan, frustrated by the lack of work the apple crop provided, prepared to head south to greener pastures. The outreach staff, including myself, found ourselves in the office more than in the field. This provided us with more time to lend our services to emergency situations than we typically had during the early summer months. In this sense, it was a timely coincidence that I, or anyone else for that matter, was present in the office that morning to receive an urgent call from the medical staff at the Bangor Health Center.
A physician at Bangor saw Edgar almost immediately that morning, and lab results were favorable, though apparently inconclusive. The physician feared that a ruptured appendix (the worst of several possible scenarios) could not be ruled out in the physical examination, despite the optimistic tone of the labs. Her plan was to refer the patient immediately to a surgeon at a hospital in the nearest urban center, Kalamazoo, for further analysis and possible surgery. As migrant workers, three challenges quickly presented themselves to Edgar, María, and InterCare. First, Hector desperately needed to return to the field to organize his workers for the day, translate for the patrón, and earn at least a half-day's wage. Consequently, Edgar and María had no transportation to the hospital located thirty-five minutes from the clinic and over an hour's drive from their temporary housing. Secondly, neither Edgar nor María spoke more than a few words of English, and according to the specialist's office, no one on staff at the hospital would be available to interpret. This despite Title VI of the Civil Rights Act of 1964 which plainly requires that all medical institutions receiving funding from the U.S. Department of Health and Human Services have medical interpreters on staff to avoid discrimination based on limited English proficiency. Thirdly, fear became a factor since no one could predict whether Edgar would be able to return home that night or if his stay at the hospital would be prolonged, how much the uninsured consultation might cost, and whether their illegal immigration status posed a risk in Kalamazoo.
The decision to face these potential challenges in order to proceed to the next stage of care, though ultimately up to Edgar, was essentially determined by the myriad of circumstances and constituencies (personal, institutional, and biomedical) linked to the illness and the afflicted. The possible ramifications of delaying treating the undetermined illness outweighed the peripheral risks (those which existed beyond the illness itself) in the mind of both the patient and the biomedical community. The point at which the treatment of disease and the "outside factors" in the lives of the patients collide is usually the point at which the Migrant Outreach Program enters the scenario, and in this case, the call was made almost immediately after the decision to proceed.
Initially, our responsibilities included tackling two of the three immediate obstacles faced by the patient-medical interpretation and transportation. Lack of transportation is a major concern for the migrant farmworker community, as well as the agencies providing services to migrant workers, such as InterCare, who depend on the patients' ability to show up to a scheduled appointment. Many farmworkers carpool, not only to and from the field every morning, but also from nation to nation, state to state, and job-to-job. Vehicles are a significant expenditure, and most families try to get by as long as possible either without or with just one vehicle devoted to work purposes.
Currently there is no agency in southwest Michigan that provides transportation (urgent or otherwise) for all migrant farmworkers seeking medical attention. An ambulance is always the best option in emergency situations, but this service tends to be very expensive. Likewise, InterCare does officially provide transportation for pregnant women who are enrolled in the prenatal MSS/ISS Program, but these women must also be eligible for Medicaid. There is one other agency that does provide transportation, but eligibility requirements include a social security number and immigrant status. Clearly, local transportation to specialist and emergency appointments is an issue that needs to be addressed as soon as possible. In the meantime, however, the Migrant Outreach Program at InterCare continues to provide "unofficial" transportation as a last resort.
In the case of Edgar and María, two of the outreach personnel would provide transportation to Kalamazoo as well as medical interpretation at the outset of the specialist consultation, at which time I would meet the team, interpreting and transporting from that point on. When I arrived at the hospital consultation, initial lab results for the patient were just about to be presented by the specialist. Luckily, these results did not indicate a need to proceed with an intrusive form of diagnosis-namely surgery-and he suggested a more tentative approach. What this meant for Edgar, María, and myself was relief; Edgar's life did not appear to be in danger (at least immediately), and there might be a less expensive treatment. The specialist explained that these results, while positive, were not in any way diagnostic, and normally he would strongly recommend further tests, though this may include a significant financial undertaking.
I knew that Edgar was still experiencing pain, significant enough that he and María would actually consider proceeding with further treatment. His only reply to the specialist was "¿cuánto será?" (How much will it be?). The doctor's response: $200 or $300. After discussing the limited work possibilities that they faced in the apple fields and the costs of the $90 for the consultation, Edgar and María decided that between the three active workers in the family and their accumulated savings it would be possible to pay for the procedure, which they scheduled one week later.
The long drive back to the countryside was a pleasant one. Edgar's pain medication seemed to be working, and the three of us drifted slowly in and out of conversation. At dusk we arrived at the apple orchard where Edgar and María thought they could get a few more apples picked before dark. We parted with an optimistic handshake. Soon, we thought, we would know what the illness was that we were facing and, perhaps, how to break free from it.
For the next several days, I was able to devote a portion of my time to Edgar's situation and how we could assist in overcoming some of the barriers to treatment that he faced. I felt a deep sense of responsibility and personal attachment to Edgar and his family, perhaps deeper than other cases because I had studied in the state of Querétaro, Mexico during my undergraduate years. We had a connection in that we each felt we had a home in both Michigan and Querétaro, and a responsibility to help others with connections to these places. For Edgar and María this involved sending money back to their extended family, and for me, personally making a positive impact in the lives of Queretanos in Michigan, as they had made an incredible impact in my life as a student in Mexico.
Since transportation and medical interpretation could be arranged through outreach, I shifted my focus to easing the financial burden that the mere diagnosis of this illness would create. In this sense, I found myself playing the roles of both outreach assistant and social worker/advocate, contacting the radiology office where Edgar's appointment was scheduled. While I was hoping to find some additional payment options that would have eased the burden somewhat, I was considerably dismayed when the staff informed me that the "photos" that the specialist described to the patients were more specifically two CAT scans of the lower abdomen, a procedure costing $615. I realized that the doctor's misquote on the price was significant and that this placed the procedure totally outside the patient's financial range.
With the help of two Camp Health Aid Coordinators, I contacted several agencies, both private and public, that in some cases provide funds for migrant workers in need of emergency assistance. In the case of the private agencies, eligibility requirements tended to be extremely narrow, and those seeking the assistance either had to be documented guest workers in the U.S. or the funds had to be disbursed to cover only specific procedures. In order to explore public funding options, I had to investigate a bit more deeply the rules and regulations surrounding Medicaid and local and State Emergency Relief Funds. I soon realized that the bureaucratic system operating at both the state and federal levels, which supposedly provides a "safety net" for the un and underinsured, has significant loopholes through which many migrant families fall.
The first areas that I explored were the regulations regarding Medicaid and Emergency Medicaid at the federal level1. While Medicaid is ultimately disseminated to clients by the Family Independence Agency by the state, federal policy determines when states must require social security and immigration status information. In the case of Medicaid, an applicant must provide a social security number or present immigration/citizenship status to qualify, though others in the family are not required to present this information. Obviously, this was not an option for Edgar who was an undocumented worker.
I then considered Emergency Medicaid options, which I knew were available to some migrant farmworkers. Federal regulations require Emergency Medicaid to become available to eligible persons "after the sudden onset of a medical condition". Eligibility here, however, is again stringent. If the applicant refuses to show proof of legal immigration status, and has entered the U.S. between certain dates outlined in specific legislation, he may be eligible for Emergency Medicaid. The patient, however, must be treated in an emergency room, critical care unit, or intensive care unit (exactly those areas we were trying to avoid with Edgar) for an illness that could result in "serious dysfunction of any bodily organ or part, serious impairment to bodily functions, or placing the patient's health in serious jeopardy" (U.S. Department of Health and Human Services website). The health care professionals that I consulted about this option were also dubious, explaining that Emergency Medicaid is primarily intended for pregnant mothers taken to the emergency room during delivery.
At the state level, there are State Emergency Relief Funds (SER), which do cover hospital services for migrant and seasonal farmworkers who do not qualify for Medicaid. Outpatient services. However, they must be accompanied by admittance to the hospital to be covered, and the program requires that applicants' families include a child under 21 years of age, proof of legal immigration status and U.S. social security number. While the state gives the local FIA office the authority to distribute these funds at their discretion, there are loop-holes written into the policy which also allow these offices to deny funding at their discretion.
At this point, we decided to turn our attention to public assistance at the local level, which InterCare had previous success in obtaining. Michigan provides funds to counties to be used to assist people with emergency situations, medical or non-medical. The individual counties are free to establish their own standards and criteria for how these funds may be distributed, and most counties in southwest Michigan have very few restrictions on who can acquire these funds.
Considering our time constraints and Edgar's eligibility status (or lack of eligibility) for other assistance, this seemed our best option. I contacted the county in which the referring clinic is located, and officials there stated that while a person in this type of situation would have been eligible to receive their emergency financial assistance, the fact that the migrant camp in which Edgar lived was located in the neighboring county made him ineligible. Even more frustrating were the officials representing the county in which Edgar and María lived who refused to appropriate their emergency funds to the family due to their undocumented status, claiming that even their presence in the agency's office would put them at risk if someone were "to call Immigration."
The day before the scheduled procedure, our resources were exhausted and our time was limited. I knew that many migrants were moving south in search of work in citrus, and we needed to communicate with Edgar as soon as possible in order to encourage a clinical follow-up. The clinic was hoping to see some improvement or diagnostic change in his condition that might determine another course of treatment, avoiding entirely the expensive CAT scan.
Edgar and María had no phone access anywhere near their home, and I found myself wandering through an apple orchard searching for them, the ground covered in a slippery, fruity film. With the help of one of the crew who noticed me comically stumbling amongst the trees, I finally located Edgar and María at their home taking their lunch break. I explained the situation, and they confirmed the impossibility of pursuing the scheduled CAT scan. Although Edgar was still concerned about his painful condition, he was reluctant to agree to a follow-up that day. Losing a half-day's wage for more tests seemed ridiculous to him, especially when the patrón had just fired three workers that week for leaving two hours early on a Sunday afternoon. Wouldn't it be better, he wondered, to wait and see what options presented themselves in Florida?
I convinced him to see the physician at Bangor one more time, offering him a ride to the clinic and promising to discuss the matter with the patrón. Putting on my best doctor's face, I went to meet with the grower to ask for leave on Edgar's behalf. Showing genuine concern, the grower agreed to our request for time off that afternoon, offering his best wishes to Edgar for a full recovery. Edgar and I chuckled at the ease with which we handled the patrón as we sped to the clinic.
A third round of lab tests again revealed nothing conclusive. I did my best to interpret the doctor's very real concern to Edgar. She could still feel something unusual during her examination of his abdominal area. The pain continued to be present, though now bearable. The doctor once again presented the options, this time reduced to either taking the risk (perhaps of a lifetime) by letting things go until Florida, and perhaps beyond, or rescheduling the CAT scan. In a sense the situation had come full circle, and again the decision was made unequivocal by the circumstances. With no diagnosis and no means to pay for one, Edgar would take his chances on the road to Florida.
Making Connections: Placing Edgar and María's Experience in a Broader
Context
During the sixteen months that I worked at Intercare my eyes were opened
to many realities of the "hidden world" of migrant and seasonal farmworkers
and migrant health centers in the U.S. Community health networks, such as
InterCare, that devote a portion of their resources to migrant health promotion
are participating in a form of health intervention analogous to international
health programs initiated by the U.S. in the developing world. Rather than
crossing political boundaries, however, this form of intervention occurs
across socio-economic and cultural borders. Just as at the international
level, local migrant health promoters must pursue their goals of sustainable
health by addressing key issues beyond the illness itself-issues like institutionalized
poverty, labor exploitation, and cultural and political domination-that
can only be reduced through large scale structural changes in the overarching
systems (social, political, and economic) that govern health care in this
country.
Unfortunately, Edgar and María's situation is not a unique one for the migrant and seasonal farmworker community. Each summer a multitude of families, most with children, experience similar challenges. While each individual case is different, certain common elements such as language barriers, lack of transportation, immigration status, living conditions, and institutionalized poverty continue to surface as major factors in the marginalization of the migrant community.
Today, as in previous years, there are those who continue to explain away the disproportionate amount of health problems and risks that migrant farmworkers face as evidence of individuals who do not take responsibility for their own primary health care. I believe that Edgar and María's experience speaks to the shortsightedness of this viewpoint. Clearly, in the case of migrant farmworkers, it is not simply a matter of patient "compliance" in the sense that a person experiences illness, goes to the doctor, takes the doctor's advice, and then proceeds on to the next stage of care. Rather, it is an on-going struggle for these people to obtain equal access to health care. Their access is restricted, seemingly at every turn, by bureaucratic barriers reinforced by poverty. It was not "non-compliance" that kept Edgar from pursuing a diagnosis, but rather the prohibitive cost of what is considered standard procedure for the majority of patients in the U.S. His illegal immigration status, lack of transportation, and limited English proficiency compounded the situation.
It does not take training in a critical approach to medical anthropology to see that political and socio-economic factors existing outside the realm of the biological have a direct impact on health in the migrant farmworker community. In attempting to reduce the barriers to equal access that Edgar faced, I saw first-hand the legislative loop-holes and eligibility requirements in the Medicaid, Emergency Medicaid, and state and local Emergency Relief Funds. While in theory these programs are inclusive of some migrant farmworkers they are simultaneously exclusive to those who are in the greatest need.
From Large to Small Scale: Redefining "Success" in Migrant Outreach
While the structural dimensions impacting on farmworker health are far from
being solved, one thing I have learned this year is that we cannot lose
sight of the positive, small-scale impacts that outreach programs make at
the local level. I have come to understand that looking at our efforts in
terms of diametrically opposed notions of success and failure would be both
frustrating and problematic. While as an agency, InterCare has a very worthy,
albeit unattainable, goal of 100% access with zero disparities, I saw success
taking place more at the micro-level, one individual case at a time.
It is interesting to note that special programs, such as the Migrant Outreach Program, are often the first to face both statewide and agency funding and job cuts, despite the fact that the individual victories that these programs consistently achieve have contributed to positive health trends at the state and national levels. Reducing the barriers to access to health care is often misconceptualized by the larger biomedical community, not to mention government agencies and funding sources, as a non-essential component of primary health care. This has put pressure on outreach programs to constantly legitimize their existence to the larger agency, institutions, and communities within which they operate. And yet the Migrant Outreach Program at InterCare continues, season after season, to be a vital, though often overlooked and under-funded, component of the basic clinical services provided for migrant farmworkers.
In relating my experience working with Edgar and María, I not only wanted to express what I perceive as some of the main issues effecting migrant health today, but also to communicate the limitations that outreach programs face. While we are able to reduce some of the barriers our patients face, we are not able to eliminate all of them. Edgar never did receive an accurate diagnosis or a treatment plan while in Michigan. Likewise, we cannot expect to single-handedly initiate the large-scale, macro-level structural changes necessary to curb high rates of preventable illness in the migrant community. We simply cannot guarantee that every individual who needs it will receive the quality care that he deserves.
We were, however, able to communicate to Edgar and María our concern and interest in advocating change on their behalf. We made an effort to build interpersonal relationships with these patients and succeeded in empowering them to actively pursue adequate health care even amidst the challenges. Ultimately, I believe that we must define our success each season in terms of the positive impacts we have made, whether on the grand-scale or minute, in the individual lives of those we serve. We must first acknowledge to ourselves and then educate the larger biomedical community in the importance of empowerment and awareness as powerful tools that begin with individuals extend to families and, eventually, to whole communities.
Should we be content with these small-scale successes? Definitely not. Standards should continue to be set high, but at the same time we must recognize the potential for subtle changes that outreach programs can have. The key is for outreach staff to fulfill this potential by setting goals at the individual level that are attainable, all while working amidst the backdrop of the larger picture. Success in this sense is a balancing act, expressed by how many faces, like Edgar and María's, we see in the waiting room again next year.
Postscript
While putting this experience into writing, I often thought about Edgar,
María, and Hector and how they fared in Florida. In August of 2001, while
engaged in an outreach assignment at the Eau Claire Health Center, I looked
up to see Edgar and María walk into the waiting room. They walked up to
the reception desk and found me, quickly introducing me to the newest, beautiful
addition to their family. "Eddie" Jr. was born in Florida, and was now coming
in for his one-month physical exam. After catching up on the past several
months in our lives, Edgar and María asked for information about how to
apply for Medicaid for their new baby boy. I was happy to help.
References Cited
Rothenberg, Daniel. 1998 With These Hands: The Hidden World of Migrant Farmworkers
Today. New York: Harcourt Brace.
1. The legal information summarized here is made available to the public on the Internet. For a more current and detailed explanation, please see the U.S. Department of Health and Human Services website, the Michigan Department of Community Health website, and the State of Michigan Family Independence Agency website.
Website Erratum
In the Mar column, Craig Janes mistakenly attributed the origins of the SMA website to Ruthbeth Finerman. That recognition should have gone to Elisa Sobo, who did the most difficult work of all—pulling together materials, designing the site and posting it for the first time. Craig Janes regrets the error. A brief statement on the history of the website is available on the SMA homepage.
Structural Violence and Anthropological Praxis
By Linda Marie Small
In thinking about Paul Farmer’s comment about “where we work” (Jan 2002
AN) and his reference to “where and what society and processes” anthropologists
study, we can apply the “where” to the infrastructure that enables our research.
With this application, though, Paul Farmer’s conception of “structural violence”
as consisting of the “social machinery of oppression” omits two primary
discourses. Missing is discussion of the discourse of social cues and the
discourse of praxis.
Our research is dependent upon an infrastructure of social machinery that
enables us to “do” science. It is one thing to do human-rights research
that is easily defined, such as documenting “who” or “how many” people are
able to vote. Social and economic rights, on the other hand, are dependent
upon interwoven networks of education, goods, manufacturing, jobs, building
materials and so forth. These “stepchildren of human rights” lend the discourses
of social cues and of praxis greater ascendancy due to the inherent need
to situate one’s research within a complex of networks.
Professors and practitioners have specialized knowledge and skills in anthropological praxis. However, their work is hedged by “structural violence” not unlike that of any social group or processes that anthropologists select to study. Anthropologists must read the discourse of social cues and speak the discourse of praxis of the infrastructure that enables science.
It is the infrastructure that supports or doesn’t support anthropological research that impacts who will work, what will be researched and who will gain (read the discourse of social cues) professional favor. Thus, the agency of anthropologists is not wholly free from oppression and marginalization by “structural” forces of funding, organizational culture and professional standing that are at work in pursuing scientific inquiry.
Resist we might. But in the end, our own agency is necessarily circumscribed by the existing infrastructure with its inherent “violence” restricting our own social and economic human rights—rights to employment, to education, to choice and to the defining of our praxis.
Prizes and Awards
Visit the awards section for information about the Basker, Hughes and Rivers award competitions. Deadlines are soon!
A Change in Editors
As of the fall, Nancy Vuckovic will take over as editor of this column.
Please address all inquiries about submissions to this column to Nancy at nancy.vuckovic@kpchr.org