Best Practices in Mobile Team Outreach

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Just west of Portland, Oregon, thousands of acres of orchards, vineyards, and berry bushes stretch out across fertile plains. Every June, these fields are closely tended and harvested by migrant and seasonal agricultural workers who have arrived from around the country and throughout the Western Hemisphere. But 2020 is different: the COVID-19 pandemic has hit this region hard, with Washington County, at the heart of this agricultural region, experiencing the second-highest rate of infection in the state by late April.  Even more concerning is the disparity in infection.  While Latinos accounted for around half of those tested for COVID-19, they were roughly 20 times as likely as other patients to have the virus.¹ “[Latinos] represented 97 percent of our positive cases,” said Eva Galvez, MD, a family doctor at Virginia Garcia Memorial Health Center, which serves this agricultural worker community, and a member of MCN’s board of directors. “My concern is that as we get more farmworkers coming in, the numbers could get higher, so I want to do more prevention.”

Virginia Garcia has quickly mobilized to address the spread by taking a radical and proactive approach to protect the agricultural worker community from COVID-19: it's mobilizing its clinics to provide testing at the farmworker camps. Every year, Virginia Garcia provides outreach to arriving agricultural workers by sending teams out to the farms that provide housing for their workers, but they have adjusted their strategy.  “We’re going to start to test people, and my hope is that we can test them before they begin work,” Dr. Galvez explained. “We want to find people [who are COVID-19 positive] before they are living and working together, so we can decrease the risk of spread.”

Health centers have a critical role in preventing further spread among those who grow, harvest, and process food, who, despite the increase in attention from news media as “essential” workers, continue to lack worker protections afforded to other worker categories.  The COVID-19 pandemic has exposed these worker health protection disparities, particularly among meatpacking plants where close worker proximity, poor ventilation, rapid line work, and cold environments have accelerated infection rates.  “We’re seeing the impact when you don’t have [sufficient] regulations, and [workplaces] are unprepared,” Dr. Galvez noted. She was a critical actor in pushing Oregon’s Occupational Safety and Health Administration to adopt emergency regulations to protect agricultural workers during the pandemic.² Even with the guidelines in place, workplaces will need health centers to assist in health and implementation education as well as testing, and Dr. Galvez is thrilled that her health center is filling that role.

“This is a public health issue,” she warned. “Wherever you have essential workers, we need to keep them as safe as we can by trying to prevent illness. So, let’s go out there and start testing, identify possible cases, and isolate them – otherwise we’ll continue to see these pockets” of outbreaks related to essential workplaces.
      

Wisconsin

Across the country, as the COVID-19 pandemic picked up speed, health centers have pivoted their efforts to keep patients safe. The Wisconsin Farmworkers Coalition, led by Family Health La Clinica (FHLC), the only migrant health center in the state, has developed a comprehensive risk mitigation strategy to protect the state’s agricultural workers and to help clinicians determine protocol for on-farm testing and education. The strategy also provides farms with best practices to ensure implementation of a statewide emergency order that outlines specific measures that must be met on farms. A Risk Mitigation Strategy document outlines Family Health La Clinica’s overall approach, including education, communication, and logistics measures, testing results management, post-outbreak support, and other considerations. The Migrant and Seasonal Farmworker Playbook and the Pre‐Arrival Site Visit and Workplace Modifications feature scripts for first engagement with farm owners, arrival at the farm, COVID-19 education on symptoms, testing, safety measures, and test responses. It also includes workflows for farm arrival and testing. A fourth document to round out their approach is Supporting Migrant Seasonal Agricultural Workers: Housing and Workplace Best Practices. This document gives growers and farm owners specific and detailed recommendations for how to implement each safety and health measure delineated in the state’s emergency regulations.

The Wisconsin Farmworkers Coalition is a multi-sector statewide group that typically meets quarterly. During an April emergency meeting, FHLC’s Chief Executive Officer, Laura Waldvogel, MSE, proposed closer collaboration to develop a more cohesive and collaborative approach, to ensure uniform messaging and strategy.  Within two days, a new steering committee had been formed and began meeting.

“It has really blossomed into something far beyond what I had anticipated,” Waldvogel noted. “It includes partners we typically wouldn’t see working together,” like migrant and seasonal agricultural worker employers, migrant and seasonal agricultural worker advocacy groups, Legal Action of Wisconsin, the Wisconsin Department of Workforce Development, a regional Occupational Safety and Health Administration (OSHA) representative, a medical college, and public health department officials from a number of counties, among others. “Both the employers and workers have been incredible,” she added.

The coalition identified gaps in the processes designed to mitigate the spread of COVID-19, and filled them. FHLC’s Chief Medical Officer, Cheston Price, MD, was instrumental in developing the risk mitigation strategy, to get to an endpoint where the health center can engage with growers and agricultural workers in a way that benefits and is supported by all parties. A Wisconsin-based health improvement philanthropy provided a large grant to support their COVID-19 educational efforts, further bolstering the process.

“We started with a survey to find out what resources [growers] might need,” Waldvogel explained. “We go on-site to do a pre-arrival assessment of the workplace and housing – it’s all voluntary – and we do a review and make recommendations. The employers have been incredible.”

As close as possible to the arrival of farmworkers, a team from FHLC begins to do on-site testing.  At first, the state of Wisconsin was not advocating for on-site testing on arrival. The coalition was hoping the state would support their position, as “it’s what we really need to do, for this vulnerable population, and employers simply couldn’t quarantine everyone for two weeks,” Waldvogel noted. Their approach, which they pushed forward, is a necessity, as is education.

“Education is probably even more important than the testing. If you don’t provide the education, many [agricultural workers] have a difficult time understanding the ways they can keep themselves safe, not just in the housing,” Waldvogel said. She also noted that education around testing was also important, to ensure that workers understand the test is only for that moment in time, and not an indicator of or guard against future infection. “Then there’s the results management, follow-up care if primary care is necessary, and outbreak support,” all of which the coalition has mapped out, and FHLC has supported.

“As we started [providing all these COVID-19 services], we got a lot of attention from the state of Wisconsin, and they asked if we could scale it up,” Waldvogel recalled. “Now we’re partnering with them.” The state has committed funding and the support of the National Guard to support FHLC’s testing and on-site work.
   

Nationwide

Among communities that lack statewide regulations, health centers may recommend their own best practices and implement strategies aligned with public health recommendations to support farmworkers, when federal and state guidance are lacking. Dr. Galvez in Oregon was instrumental in securing her state’s regulations after partnering with a legal rights organization. She encourages her fellow clinicians at health centers to take part in such a medical-legal partnership because such regulations, as opposed to statewide guidelines or no guidance at all, can have a profound impact on agricultural worker health.  Read more about Dr. Galvez’s medical-legal partnership to secure emergency regulations in Oregon on Migrant Clinicians Network’s blog: https://bit.ly/3dSAcAi [3]. “Community health centers can play such an important role in helping our essential workers stay safe on the job,” added Amy K. Liebman, MPA, MA, Director of Environmental and Occupational Health. “In many places they are trusted sources and can help educate workers in a language they understand, using a culturally competent approach.”

FHLC hopes its materials will benefit other health centers; they’ve made their resources and education widely available on a site dedicated to the coalition’s COVID-19 work: https://www.famhealth.com/wi-msaw-covid-19.html [4].“We make no claims that [the information on the website] is perfect. It’s constantly in evolution, and as soon as we have it out, it’s obsolete because things change,” Waldvogel admitted. “But we put it out there because we want it to benefit everyone.”
    

Access FHLC’s guiding documents on their website:

Pre‐Arrival Site Visit and Workplace Modifications: https://bit.ly/2TDI4xJ [5]

Supporting Migrant Seasonal Agricultural Workers: Housing and Workplace Best Practices (COVID-19): https://bit.ly/2M1tko4 [6]

COVID-19 and Wisconsin’s Migrant and Seasonal Agricultural Workers: Family Health La Clinica’s Risk Management Strategy: https://bit.ly/2X0NzbV [7]

Migrant and Seasonal Farmworker Playbook: https://bit.ly/36uIYlq
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Best Practices in COVID-19 Mobile Team Outreach: Questions to Consider

Pre-Arrival 
Contact the grower to determine:

• Schedule: When do farmworkers arrive? Can the health center team provide testing immediately on arrival?
• Precautions: What precautions and standards of practice are in place to protect farmworkers:
  • On the job?
  • In farmworker housing?
  • During transportation to work?
  • If a worker exhibits symptoms of COVID-19?
  • If a worker’s test returns positive?
  • When in isolation?
• Resources: Does the grower need more education or resources (signage, PPE, handwashing stations) to implement precautions before farmworker arrival? To communicate these precautions once farmworkers have arrived?
• Logistics: Is there a suitable outdoor area where the health center team can facilitate testing?

Arrival and Testing 
The mobile team must determine:

• Safe arrival: How will the mobile team maintain distance while in transit?
• Testing protocol: Develop and practice an in-field testing process including:
  • Donning and doffing PPE;
  • Administering swab tests;
  • Preparing the tests for transport to the testing facility; and,
  • Returning to the farm to provide results. 

Farmworker Education

• Training: What farmworker education can the mobile team provide?
• Materials: What handouts, signage, other resources can be provided?
• What do farmworkers need to know if they feel ill? What are the steps to getting care and what are their rights as essential workers?

Update on Federal and State Requirements Regarding Farmworkers, including H2A Workers, and COVID-19

Here is an update on federal requirements for growers on H2A workers and other farmworkers.

Testing on Arrival: MCN strongly encourages health centers to build community coalitions to coordinate testing for all farmworkers for COVID-19 upon arrival. Testing of H2A workers upon arrival to the United States is not federally required [9]. Individual states and some farms may have their own testing requirements for arriving international workers. Consult your state’s Department of Labor [10]. Additionally, individual health centers have developed protocols to test upon arrival, in conjunction with local growers.

Quarantine after Arrival: Quarantining for 14 days after worker arrival will reduce the risk of spread, when testing is not available or is otherwise unfeasible. Many farms have chosen to quarantine instead of test. Under the Family First Coronavirus Response Act (FFCRA), workers who are required to be quarantined are to be provided with paid sick leave, including H2A and non-H2A workers, and regardless of immigration status or authorization. This requirement is in effect until December 31, 2020. Read the US Department of Labor’s infographic guidelines in English [11] or Spanish [12].

Daily Screening: Federal guidelines ask growers to “consider screening farmworkers for COVID-19 signs and symptoms.” Health centers and growers can work together to develop processes to support daily screening and next-steps if a worker is found with symptoms.

Sick Workers: Workers who are unable to perform their duties because of COVID-19 -- whether because they have symptoms that prevent them from working or simply because they are COVID-19 positive and need to be isolated -- are to receive paid sick leave of up to two weeks or 80 hours of paid sick leave at their regular rate or minimum wage, whichever is higher.  This is a federal Department of Labor requirement. Read the US Department of Labor’s infographic guidelines in English [11] or Spanish [12].

Federal Guidelines: Read the Interim Guidance from CDC and the US Department of Labor [9] for more on the CDC’s recommendations relating to farmworkers and COVID-19.

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