PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1106-1107
COMMENTARY |
Health Care Research on Migrant Farm Worker Children: Why Has It Not Had a Higher Priority?
The article by Weathers and her coinvestigators in this issue titled "Health Services Use by Children of Migratory Agricultural Workers: Exploring the Role of Need for Care"1 is only the fourth article published on the health care of migrant farm worker families in Pediatrics since 1948, excluding policy statements by the Committee on Community Health Services.2,3 During the past 54 years the only clinical or health services research on children of farm workers published in Pediatrics included 1 article in 1972 and another in 1974 on lead exposure and toxicity.4,5 A third article, published in 1962, did not report findings of a research study but called on medical schools and pediatricians to become more actively involved in the study of the health problems of migrant farm worker children.6 The small number of publications describing clinical and health services research related to migrant farm worker children in Pediatrics is consistent with the experience of other peer-reviewed journals and is a reflection of the very limited number of research studies that have been conducted in this high-risk vulnerable population. As referenced in the Weathers article, a 1998 Institute of Medicine report highlighted this concern by stating that there is "a glaring and significant gap in the scientific literature" for research on children of migrant farm workers, especially undocumented workers.7In setting research priorities, funders usually consider the magnitude of the problem, the ability of the research to contribute to better health outcomes through improvements in care and/or better health policy, and a sense of fairness or social justice for disadvantaged populations. Therefore, why have government agencies and private foundations not supported more studies of these vulnerable, disadvantaged children?
Is the magnitude of the health problems faced by farm workers and their children too insignificant to warrant sustained research funding? The magnitude of a health problem is a reflection of the size of the affected population, the prevalence of health conditions, and the severity of these conditions. The size of the farm worker population is substantial. The National Office of Migrant Health estimates the size of the migrant and seasonal farm worker population and their dependents somewhere between 3 and 5 million people.8 This vulnerable population has a high prevalence of many acute and chronic medical conditions. Migrant children frequently suffer from nutritional deficiencies such as iron deficiency anemia and are likely to have other vitamin and trace mineral deficiencies.9 Today, despite federal laws designed to protect farm workers from the health consequences of pesticide exposure, farm workers and their children continue to be exposed to these disabling and potentially fatal toxins throughout the country. These acute and chronic conditions can be quite severe. In 1972, Dr Peter Chase reported that the infant mortality rate among migrant farm workers’ families in Colorado (63 deaths per 1000 live births) was 3 times the United States overall rate.9 In 1987, agriculture became the county’s most hazardous occupation with a work-related fatality rate of 52 per 100 000 workers.10 Clearly, the magnitude of the problem is not insignificant.
Can studies of migrant health be properly designed to lead to better health outcomes? Answering this question requires an understanding of 3 challenges researchers must overcome to study the health of migrant farm worker children: first, establishing methods for defining and enrolling the eligible population; second, having relevant measurable outcome measures; and third, having meaningful community participation in both the planning and implementation of the project. The work by Dr Weathers and her coinvestigators demonstrates that these challenges can be overcome. The study conducted in eastern North Carolina used a population-based approach that surveyed migrant households using a multistage, partially random sampling technique to identify families with eligible children. This avoided the selection bias that would have been present if the survey was administered only to families receiving care in migrant health clinics. The investigators modeled their outcome measures on the Behavioral Model of Health Services,11 a well-regarded approach that explains how perceived need for medical care, enabling resources to access care, and individual/family sociodemographic factors influence service use. The investigators involved the farm workers in the development of the survey, used migrant health outreach workers as interviewers, and were careful to maintain the trust of the farm workers by using "protections of anonymity and indirect questioning to increase the accuracy of information obtained about the respondents immigration status." Trust is a critical element in the ability to care for undocumented migrant farm workers. In 1968, I worked on a Student Health Organization project that helped to start a migrant health clinic in Fort Lupton, Colorado, and after residency I worked as the clinic pediatrician for 2 years. The community boards and staff were sensitive to the farm worker fears of being undocumented workers as well as possible negative feelings of being "studied." The Weathers study, because of the investigator’s cultural sensitivity and careful planning, has overcome each of these challenges. Well-done health services research can increase our understanding of how health services impact the adverse health outcomes that result from the interactions between individual host factors and environmental exposures to infectious agents, toxins, and trauma (emotional and physical). In the Weathers study, users of health care services were more likely to report that their children had poor health, and the findings suggest that these parents will overcome many barriers when they feel that their child’s health is poor. The study identifies and quantifies the impact of barriers such as not having health insurance, not speaking English and having an available interpreter, not being eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children, not having transportation, and being undocumented. These barriers are significant, as more than half of the families reported an unmet child health need. Clearly, valuable studies can be appropriately designed and conducted.
Are farm workers and their children undeserving of resources being spent on health care research? From a fairness and social justice perspective, migrant farm workers and their families continue to live like impoverished third world people despite the organizing efforts of the United Farm Workers Union and Cesar Chavez. Free markets, economic prosperity, and globalization have all failed to greatly improve the health and welfare of this vulnerable population. The "trickle down" theory of economic development has not reached migrant farm workers despite 67 years of exposés dating to the publication of "Factories in the Field" in 1935. Our state-based fragmented programs including Medicaid, the Nutrition program for Women, Infants, and Children, and prenatal care programs fail to meet the needs of these families. We have been unable to design health care systems that counter the impact of poverty, lack of insurance, a mobile lifestyle, inability to speak English, and social isolation. Clearly, the farm workers who keep America healthy by planting, cultivating, and harvesting the country’s fruits and vegetables are deserving of having health care research resources committed to making their families healthier.
How do we answer the key question: Why have government agencies and private foundations not supported more studies of these vulnerable, disadvantaged children? Funding research in this area should have been given a high priority. Although I don’t know the answer for sure, I suspect that the explanation has to do with our fears about being overrun by immigrants (documented and undocumented) and our dependence on their cheap labor, especially in agriculture. Our ambivalence results in passing laws that restrict immigrant access to Medicaid and SCHIP while many policy makers remain deeply disturbed and embarrassed by the continued exploitation of farm workers. Has this ambivalence resulted in the inadequate funding of migrant health research? Or could the reason be more disturbing—an underlying prejudice and intolerance in our society? Whatever the reason, now is the time for research funders and pediatric researchers to close this "glaring and significant gap in the scientific literature." We must all accept responsibility for its existence and work to close it.
Department of Pediatrics
University of Colorado School of Medicine
Children’s Hospital
Denver, CO 80218
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FOOTNOTES
Received for publication Sep 11, 2002; Accepted Sep 11, 2002.
Address correspondence to Steve Berman, MD, Children’s Hospital 1056 E 19th Ave, B032 Denver, CO 80218. E-mail: berman.stephen{at}tchden.org
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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