March 2007 | Back to Table of Contents

Pulse

Field Medicine

Rural Minnesota has always welcomed migrant workers. But making sure they get health care hasn’t been easy.

When U.S. Immigrations and Customs Enforcement raided Worthington’s Swift & Co. meat-packing plant last December, James Harris, M.D., wasn’t surprised. A Worthington resident and general surgeon with Avera Worthington Specialty Clinics for 20 years, he had seen previous raids. But this one was different.

Hundreds were arrested at the Worthington plant in a crackdown on allegedly undocumented workers at seven Swift plants in several states. Altogether more than 1,200 people were arrested, most of whom were Hispanic.

Almost immediately, the town’s atmosphere changed. Many Hispanic families stopped going to church and community functions; some, including a handful of patients from Avera clinics, followed family members back to their home countries.

Each year, more than 25,000 people, mostly of Hispanic descent, migrate from Mexico, Central and South America, and south Texas to rural Minnesota communities such as Olivia, Moorhead, and Montevideo to help on farms during the warmer months. Others stay year-round to work at meat-packing and poultry-processing plants such as Jennie-O and Swift.

It’s difficult to say how many are undocumented: About 9.3 million immigrants are living in the United States without the appropriate papers, according to a 2004 Urban Institute report. In Minnesota, between 20 percent and 29 percent of the foreign-born population is believed to be undocumented. (One physician interviewed for this article, however, estimated that as many of 40 percent of Worthington’s Hispanic immigrant population may be living here without legal documentation.)

Whether they’re documented or not, one issue is clear: Migrant workers need health care, and many are not getting it. “Patients without documentation are reluctant to seek care until their condition stops them from working,” says Joan Altenbernd, executive director of Migrant Health Services Inc. in Rochester, a private nonprofit organization that has served migrant and seasonal farm workers since 1973. Migrant Health operates nine facilities in Minnesota and North Dakota, three of which are open year-round and two of which are mobile units. “They can be reluctant to access health care in the rural communities because of immigration issues, language barriers, ability to pay, and cultural differences, among other things.”

Same Diseases, Different Needs
Migrant workers are not much different than other residents of rural Minnesota when it comes to their medical needs. Diabetes, hypertension, hyperlipidemia, and mental health issues are frequent reasons for clinic visits. Christian Morgan, M.D., one of four primary care physicians at the Sioux Valley Clinic in Worthington, occasionally sees patients with tuberculosis, hepatitis A, parasitic infections, and dysentery. “I would say that they are definitely few and far between, but we do see them more in migrant Hispanic populations than we do in the Caucasian population.”

What is noticeably different, however, is when many migrant workers enter the health care system and how they approach their care. “On average, they work 12- to 16-hour shifts, they rarely have medical leave or even paid time off, and they worry about losing their jobs if they take an afternoon off, so it’s really hard for them to find the time to get the care they need,” says Mike McMullin, a physician assistant at the Migrant Health Services clinic in Rochester. “They are very rarely in here for coughs, scrapes, and runny noses. By the time they reach us, they can be pretty sick.”

Identity issues can also directly affect the care migrant workers receive. In most cases, undocumented workers have a birth name and a “work name,” an alias they’ve created that might be on a fraudulent Social Security card or other document. When they seek care, they may become confused about which name to use.

On one occasion, Dan Fuglestad, M.D., a family medicine physician at Affiliated Community Medical Centers in Willmar, was about to examine a woman whose patient record indicated she was 39 years old. He eventually learned her birth name, found a file for her under that name, and discovered she was actually 51. “So now I am thinking colonoscopy, mammography—screenings I would probably not have considered if she were actually 39 years old,” he says.

Beyond Language
It’s no surprise that conquering the language barrier is one of the biggest challenges for those caring for migrant workers. Morgan and Fuglestad are both fluent in Spanish, as are many nurses and receptionists at Migrant Health Services and other clinics that serve migrant populations. Affiliated Community Medical Centers’ Willmar location has two full-time interpreters and one part-timer. Signs and posters in the clinic are in Spanish and English, as are written materials.

But language is only part of the challenge. Understanding migrant workers’ beliefs about health care and medicine is as important as being able to communicate with them, say providers. Morgan, for example, learned that many people from Mexico believe that injections are curative, regardless of the illness that afflicts them. Being aware of these perceptions has helped him educate his patients. “I acknowledge their belief systems, and then I talk with them candidly to help them understand how different treatments work,” he says.

Morgan is unique among physicians: He spent time in Guatemala as a child; worked as a missionary in Mexico, Ecuador, and Colombia; and cared for underserved Hispanic populations in California and Utah before arriving in Worthington two years ago. Few doctors can claim such experience. And only a handful are adequately trained—either to speak the language of their patients or to understand the culture. “I have not seen a lot of crash courses in this area,” Morgan says of the customs and beliefs of migrant workers. “But I definitely think it could help.”

Compromised Trust
Still, the fallout from the recent Swift raids has added a layer of distrust between migrant workers and the rest of the community that wasn’t present before and that language and cultural understanding can’t easily erase.

Morgan has seen more appointment cancellations and even a few cases of post-traumatic stress prompted by workers’ witnessing or enduring detentions, arrests, and/or deportations. It concerns him that migrant and undocumented workers’ fear may be keeping them from getting the health care they need. “A big part of my job is establishing trust,” he says. “Once they understand that providers are here for their health and well-being, and that we don’t get involved with immigration laws, they come through our doors.”—Jeanne Mettner