Clinical Topics in Migrant Healthcare: Head to Toe
Thursday, January 14, 2016
Barbara Hollinger (Emeritus), UC Davis
Editor's Note: Barbara will be presenting on clinical topics in migrant healthcare at the Western Forum for Migrant and Community Health in Portland, OR, February 24-26
Have you ever wondered when taking a history or doing a physical assessment of a farmworker, what is different about their risk profile than other clients? According to the Bureau of Labor Statistics, US Department of Labor, agriculture continues to rank among the most dangerous industries. How can clinicians best care for the farmworker population?
When I began teaching Family Nurse Practitioner (FNP) students at UC San Francisco 21 years ago I quickly learned that I was the only faculty in our department with any rural clinical experience. I had just completed ten years as a FNP at Firebaugh Community Health Center in the California Central Valley. It served a predominantly farmworker population. I wondered what I could share with developing clinicians that would sensitize them to the special needs of the farmworker population and encourage them to consider rural health as an employment opportunity. The result was a 20-hour Farmworker Primary Healthcare course and the placing of many students in rural clinical residencies.
Here are some examples of what will be covered in the session.
Taking an Occupational History
· A thorough occupational history is a good starting point. Some questions to consider are: Does the client have a preexisting condition that will affect his work, such as asthma, that will be triggered by constant dust exposure?
· What specific job tasks does he/she do? A client who works “in grapes” could be doing any of the following tasks; planting new vines, tying vines onto trellises (on their knees), applying sulfur or other chemicals, harvesting table grapes, laying out grapes to dry for raisins, or working in the wine industry. Each task carries different risks for musculoskeletal injury or overuse.
· Is this a new immigrant who may never have had a vision, dental or any medical care in the past? Just like with many of the newly insured Affordable Care Act clients, there may be long-standing health issues that have never been addressed.
· What is this client’s social situation? Is this client a single male or youth living alone or part of a family group? Access to healthy food and who cooks is especially important for diabetics.
Factors to Consider
What are the physical, chemical, or biological exposures a client might experience, as well as psychological stressors?
One physical exposure is heat. Temperatures in the California Central Valley often rise to 110˚ F by midday in summer months. Workers paid piece rate rather than a fixed salary will sometimes limit their water intake to decrease bathroom breaks, increasing their vulnerability. Pregnant women and clients on certain medications such as antihistamines are especially at risk.
Chemical exposures include pesticides, fungicides, herbicides, defoliants, fertilizers and solvents. Clients mixing and applying chemicals are at highest risk but pesticide residues remain on plants after application and observing safe reentry times is essential to minimize worker exposure. Since poor housing with inadequate laundry facilities is a constant issue for farmworkers, clothing contaminated with pesticides are often worn multiple times between washings or are brought home, exposing other family members.
Biological exposures can include insect and spider bites, fungal infections such as coccidiodomycosis, also known as Valley Fever, and tetanus. For example, a tree farm worker who becomes ill may have had tick bites and should be evaluated for Lyme disease.
Psychological stressors are also important to consider. Undocumented migrants are constantly in fear of deportation. Many families worry about children living with relatives back home and strive to bring them to the US for reunification. Some individuals may be self-medicating with alcohol or drugs to deal with their anxiety or depression.
Going System by System
The workshop will explore system-by-system what areas of special risk a clinician should consider when caring for the farmworker population. Here are some examples related to skin:
A client with a past medical history of eczema may be at increased risk of absorbing pesticide residue due to a break in the skin’s integrity. A citrus worker may have greater skin or clothing contact with pesticide residue because the foliage is very dense compared to some other orchard crops. Contact dermatitis is a common agricultural worker complaint and can be allergic, irritant, or contact urticarial. Certain crops such as garlic, chilies, or onions are irritants for those who handle them. Workers along western coastal regions may be exposed to poison oak, causing allergic response, while most persons touching stinging nettles will have a response on contact. Clients whose work keeps their hands or feet damp for long work periods may experience increased incidence of fungal nail infections.
Clinicians should consider potential photosensitivity reactions when writing prescriptions. For example, workers prescribed medication in the tetracycline class are subject to photo sensitivity reactions by exposure to direct sunlight or UV light for up to five days after completion of the medication. Even sunscreen is not very helpful, so clients must be prepared to keep their skin completely covered to minimize reaction.
Clinicians working in community health centers are those with the expertise in what their agricultural worker clients are experiencing. The Western Forum for Migrant & Community Health is a wonderful opportunity for clinicians to share what they are learning from their clients with other providers. The Clinical Topics in Migrant Healthcare: Head to Toe session will include an open forum to exchange ideas. A Farm Worker History and Physical Assessment Checklist will be discussed, with participant ideas incorporated. The result will then be shared as a possible tool for clinicians to take away from the session.
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