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In Immokalee, Florida, the nation's tomato capital, the coronavirus has taken hold, with almost 1,000 cases recorded since April. Overcrowding in farmworker housing, during transportation to worksites, and while laboring in fields has made farmworkers particularly vulnerable to the virus. Now, thousands of migrant farmworkers are leaving the region and heading northward as the summer season progresses, traveling to farms across the South and the East Coast.
Seth Holmes, MD, PhD, a medical anthropologist and physician, headed to Immokalee early into the pandemic to provide support for health advocates, community organizations, and public health officials. Earlier this month during a Migrant Clinicians Network webinar [3], Dr. Holmes provided a snapshot of farmworker support and COVID-19 response in southwest Florida. Joining him in conversation was Gerardo Reyes Chavez, senior staff member with the Coalition for Immokalee Workers [4], a world-renown worker-based human rights organization that has successfully pushed for improved conditions for farmworkers in the region. Dr. Holmes highlighted the widely collaborative and proactive nature of the response; Reyes delineated the limitations of its effectiveness when confronted with the exploitative and racist structures embedded within industrial agriculture that leave farmworkers particularly vulnerable to the virus and with limited avenues of redress.
“You hear the job that we do is essential,” Reyes said, speaking about farmworkers, “but you realize as a worker you are not treated as essential. You are treated as dispensable.” Health recommendations “don’t make sense when you are poor,” he added: maintaining six feet of separation is impossible in crowded housing and transportation, and where workers don’t have the means to obtain less crowded alternatives; shelter-in-place orders didn’t apply to “essential” workers, but farmworkers often lack the political and social capital to advocate for their health needs on the job; testing and hospitalization are difficult in deeply rural locations where health services are far and transportation is limited. Dr. Holmes outlined the efforts and engagement of organizations including international NGOs Doctors Without Borders [5] and Partners in Health [6] to reduce the spread despite these widespread and entrenched limitations, including by providing culturally and linguistically appropriate community health education, regular and accessible testing, contract tracing, resources for isolation, and case management for migrant patients through MCN’s Health Network [7].
Further north, clinicians and their community partners had more time before farmworkers arrived to organize. Now, they are implementing their outlined strategies and workflows. With limited or no regulation on the state and federal levels around COVID-19, each farm owner has his or her own approach to coronavirus worker health and safety, and the farmworkers themselves, arriving from around the country and the world, have differing levels of understanding of the virus and how to protect themselves. Farm owner and farmworker engagement is therefore critical to developing an effective region-wide strategy. Joining Dr. Holmes and Reyes on the webinar were Lori Talbot, MD, a physician serving farmworkers through her private practice South Cumberland Medical Associates [8] in rural New Jersey, and Melanie Finkenbinder, MD, a family physician and medical director of the agricultural worker program at Keystone Health [9], a community health center in Pennsylvania. Dr. Talbot’s first COVID-19 case was a year-round farmworker who was intubated while in the ICU. Recognizing that the virus had already arrived, she called the farm owners of local farms and offered to test farmworkers during her lunch break. She also discussed the implications of testing with the farm owners, requesting them to ready their farmworker housing for isolation and quarantine. She tested about 200 workers over five days with a 17 percent positive rate. One of the camps, she said, had 63 of 90 workers test positive – a 70 percent positive rate. Dr. Talbot has been working with a loose coalition of agencies in preparation for the biggest increase in workers that the region expects in the coming days, for the blueberry harvest, when roughly 10,000 farmworkers arrive, and for which Dr. Talbot’s lunchtime approach would be inadequate. Dr. Talbot also noted that up to 40 percent of farmers are refusing to let workers be tested, speculating that they don’t want to draw attention to their farms, their provided housing, and their workers, all of which may not be up to regulation, and complicating efforts to limit the spread of COVID-19.
Dr. Finkenbinder’s health center has implemented a “no-touch” outreach model with a focus on COVID-19 education ahead of the height of their agricultural season. While her region has not yet seen many COVID-19 cases, “we’re getting a little nervous from what we’re hearing from Florida and South,” she admitted. Keystone is reaching out to some health centers in Florida to better open communication channels in recognition that most of their workers will arrive from there. She says farm owners in her region have been eager to prevent an outbreak. The collaboration has been “an exciting opportunity to build our relationships” with farm owners. Her team has reached out to local farm owners, both large-scale corporate farms and small family farms, to offer to help build a prevention strategy, including providing an on-site visit to help build it. Keystone Health has modified numerous programs to better serve farmworkers when they arrive, including “open access telemedicine,” a pilot program for larger camps with good wireless access for workers.
The new systems, workflows, and partnerships in place, noted panelists, are still in progress as the science develops and the realities on the ground shift. “It’s a huge moving target,” admitted Ed Zuroweste, MD, Founding Medical Director of Migrant Clinicians Network and a co-host of the webinar, when speaking about testing.
“The coronavirus, it’s [unclear] how long it will last... Part of what we’re doing is building these systems fast, because they’re needed now, but also [we’re] strengthening them for the long term of this virus – but also beyond this virus,” noted Dr. Holmes. While the pandemic won’t last forever, future emergencies – new viruses, natural disasters, climate change – will always be on the horizon. “The people who are essential frontline workers who feed us and have to keep working, and [who] live and work in difficult circumstances that make them more likely to be at risk for different illnesses, need stronger systems,” and to strengthen those systems, that requires partnerships, Dr. Holmes added. As is evidenced in community health centers around the country, partnerships are growing rapidly. How they will reshape community health and response to emergencies in the long term has yet to be seen.
Watch the entire webinar, “COVID-19 and the Realities for Farmworkers and the Clinicians Who Care for Them: A Learning Session.” Visit our Archived Webinars page [10] and our Upcoming Webinars page [11] to see all of our COVID-19 related webinars, including many in Spanish. Be sure to sign up for our updates [12] to hear about upcoming webinars.
An Inside Look At: Keystone Health in Pennsylvania
Melanie Finkenbinder, MD, is a family physician and medical director of the agricultural worker program at Keystone Health in Pennsylvania. Keystone’s Agricultural Worker Program developed five primary responses to COVID-19, which they are now implementing at their sites throughout the state:
1. No-Touch Outreach Model: “We realized that if we wanted to do physical outreach... we’d need to maintain distance,” Dr. Finkenbinder noted. Their no-touch model:
- Consists of a team that looks different throughout the state, but may include a nurse, a medical assistant, and outreach coordinator, and, if needed, an interpreter.
- Asks the supervisors to do a check of farmworkers’ temperatures before the outreach team arrives, to reduce close contact between farmworkers and the outreach workers. “This doesn’t always happen, but we use it as an opportunity to talk to the growers and supervisors about the practice of doing daily health checks,” she said.
- Is entirely outdoors, with social distance cues.
- Focuses on group education around COVID-19, including posters in line with CDC recommendations and modeling of proper distance, use of masks, and handwashing.
- Provides modified health screenings: The team shifted their focus from close-contact screenings of hypertension, diabetes, and HIV, to depression, substance use, and human trafficking. “These screenings can be done from a distance, and they address problems we expect to see more of at this time,” Dr. Finkenbinder noted. Next steps for positive screenings are conducive to telemedicine.
- Provides PPE for nurses if a physical exam is necessary, to not ignore the needs of those patients who require touch.
2. Supporting Farm Owners and Advocating for Workers: As with other communities, Keystone has found that the pandemic has pushed them to reach out to and develop stronger ties with farm owners, who are eager to avoid outbreaks on their farms. Keystone built guidelines for farm owners, which leaned on both CDC and statewide guidelines, and shared that with them on initial calls and emails. They also offer assistance to develop a prevention strategy including an on-farm consultation.
3. Building Partnerships: Keystone has also built stronger partnerships with local organizations, state government, and agricultural worker programs as a result of the pandemic. Information sharing through webinars and panels, advocating through new avenues, and sharing guidelines, plans, and best practices, and partnering to solicit and distribute donated masks to farmworkers are just a few ways that the partnerships have expanded Keystone’s ability to assist local farmworkers.
4. Primary Care Service Delivery Changes: Previously, to address the primary care needs of farmworkers, Keystone transported “large groups of workers to a crowded clinic, which is obviously not an option at this time,” Dr. Finkenbinder said. Keystone initiated numerous adjustments to primary care for farmworkers including:
- Providing transportation for just a few farmworkers at a time.
- Screening occurs before boarding the bus, masks are required, windows are open, and disinfection takes place after every use.
- An outdoor waiting room augments the limited indoor waiting area, which has been redesigned to allow for distancing.
- Education is provided throughout, including with distancing cues and COVID-19 educational videos.
5. Telemedicine: “The changes that we’re making in the clinic and that we have to make with transportation are going to decrease the capacity to see patients in our clinics, so we are simultaneously increasing capacity to care for workers via telemedicine,” Dr. Finkenbinder noted.
- On-call provider when the outreach team is in the field.
- A registry of patients with diabetes and hypertension:
- Returning workers will be registered by phone.
- Registered workers will be provided a telemedicine appointment, before the outreach team comes to their farm.
- Then, during the outreach trip, a nurse can deliver medication, check their A1c and/or blood pressure, and draw labs that have been ordered. They can also distribute blood pressure cuffs to those patients.
- An additional telemedicine follow-up can be arranged if needed.
- For camps with additional barriers – like a large population of people requiring interpretation, or poor cell or wifi reception, or a high incidence of chronic disease – the outreach team will include a provider.
6. Open-Access Telemedicine: A newly piloted program offers farmworkers who live in camps with good wifi reception “telemedicine office hours,” during which a provider is on call for anyone to call in for any concern, no appointment needed. A QR code on the flyer guides the patient directly to the virtual waiting room of the provider.
An Inside Look At: Immokalee Farmworker Community Partnerships
Seth Holmes, MD, PhD, a medical anthropologist and physician, and Gerardo Reyes Chavez, senior staff member with the Coalition for Immokalee Workers (CIW), provided a brief snapshot of some of the work that a broad coalition of farmworker and community advocates, health centers, public health, and international health organizations have begun to address COVID-19 in the large agricultural region surrounding Immokalee, including:
1. Community Education: Many of the groups, including the Coalition of Immokalee Workers, Doctors Without Borders, and Partners in Health, have developed and distributed education on the virus in a variety of languages. The local radio station, with which Reyes works, has been instrumental in distributing up-to-date information. Dr. Holmes noted that communication strategies have required greater attention because farmworkers have received contradictory information. Reyes noted that unique collaborations helped to address communication flow concerns, including a collaboration between the police department and the local Department of Health to use a sound system mounted onto a vehicle to broadcast messages about social distancing into communities that may otherwise not receive such education.
2. Testing: A broad coalition of partners, including the Florida Department of Emergency Management, the county Department of Health, the fire department, the sheriff’s department, CIW, and Healthcare Network of Southwest Florida, provided testing in the center of town starting at the beginning of April. Testing is now provided five to six days a week. “The move toward having multiple days of testing has taken many partners working together with community organizations,” noted Dr. Holmes. While testing has expanded, farm owners have been inconsistent in their support of testing, he said, and testing needs to continue to expand. “The positive rates have varied greatly,” he added, indicating that it’s as of yet unclear, despite increased testing, what the positive rate really is.
3. Contact Tracing: As testing expands, so has contact tracing, although contact tracing is still nascent, Dr. Holmes said. The Department of Health and Partners in Health were two of the partner organizations that had begun contact tracing.
4. Resources for Isolation: Both Dr. Holmes and Reyes noted the incongruence between health guidelines on isolation and the reality for farmworkers, who have low income, little savings, and no additional resources to isolate away from family or other farmworkers. Funding from a number of Florida departments around health and emergency management has begun to flow, but Dr. Holmes is concerned about the speed at which it is assisting people, and the continuing and rising present need for resources.
5. Health Network: Dr. Holmes gave a generous shout-out to Migrant Clinicians Network’s Health Network, our virtual case management system, to assist patients who may test positive for COVID-19 but plan to travel north for work. Health Network will assist in finding the farmworker resources in the new community, including links to a new health centers, transferring of medical records, and more.
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