Farmworkers’ experiences working during wildfires and impacts on health (Hyland and Gordon, 10/16/24)

This week, in commemoration of the 2017 Tubbs Fire, which destroyed over 5,000 homes in Santa Rosa, we had a really special presentation by two researchers from the Berkeley School of Public Health and Berkeley Law School on the impact of the Ag Pass program and wildfire smoke on Sonoma County farm worker health.  

If you can, please watch their presentation. A recording is available HERE.

It was both fascinating and disturbing to hear two researchers talk about the place we live and practice medicine-- and where thousands of vulnerable farm workers face dangers from our local policies during fire season.

• AB1103: California law that established a "Livestock pass" in 2021, work authorization program, allowing workers back into evacuation zones during natural disasters
• Counties have interpreted this law as permitting them to allow workers into evacuation zones
• Unfortunately, no occupational health analysis (by Cal-OSHA) was done in the passing of this law
• From 2017-2022, such passes were handed out in an Ad-Hoc manner by the Ag Commissioner, often based on personal contacts and phone calls

In 2022, the Sonoma County Board of Supervisors (BOS) passed their own version of the Ag Pass, which allows farmworkers back into an evacuation zones for "critical activities". The SoCo Sheriff decides when Ag Pass is activated.

In 2023, the local law was amended to include "grape harvest" as a "critical activity"

SoCo Ag Pass has three components:

1) Fire safety training (4 hours, no smoke or other exposure training required)

2) Apply through the SoCo Ag Commissioner

3) Go to the SoCo Sheriff's office to obtain the Ag Pass card

(this requires photo identification, address, phone number)

***

We have data from Sonoma County on the health impacts of wildfires on local health: 

• 25% increase in ED visits for respiratory symptoms
• 33% increase in hospitalizations for respiratory illnesses
• 18.7% increase in asthma prescriptions
• Disparities based on race and SES

This project was a collaboration between the Human Rights Center and Berkeley Public Health. Goal to examine health, physical safety, economic security, and data privacy

Law and policy analysis, health survey with overall goals to provide recommendations to Sonoma County and the State of California to improve health and safety of farm workers working in fire evacuation zones. 

Recruited local farm workers and trusted figures

Recruited farm workers: gain understanding of AgPass, their experience working previously in fire conditions (and symptoms), what information they need if they are working in wildfire conditions again, economic concerns related to wildfires.

1000+ workers from all over the county, 60% male, ~41 median age, 13 years on average experience working in agriculture

Experiences working during wildfires:

• 75% reported having worked during wildfire
• 64% received some protective equipment from employer
• many had to reuse
• many given surgical mask (rather than N95)
• 70% reported short term health impacts
• 36% who had health impacts indicated they lingered over time
• Mental health impacts

Barriers to accessing health care

• >50% reported no health insurance
• 39% difficult to get appointment at clinic (hours, days open, etc)

Gaps seen in the Ag Pass program as it relates specifically to health: 1) No consideration of short or long-term health effects to workers when Sheriff activates Ag Pass 2) Lack of criteria when Ag Pass can be activated (e.g. AQI level) 3) No health monitoring during/after wildfire events

Very real tension in this population between health and economic security. At baseline 75% are spending 50-75% of monthly income on rent (recommendation is 33%). If there is fire/flood/extreme heat, and farm workers cannot work and do not get paid, they cannot make their basic needs. Even though people are worried about health impacts of wildfire, even more are worried about financial impacts. 58% continued to work despite feeling sick because they needed income and were worried to lose the job. 

Most farm workers are most worried about paying for rent, groceries, gas, medicine/healthcare

Physical Safety Results

• There is no process to communicate with individuals who are reentering an evacuation zone.
• Currently employers are responsible to ensure workers leave in time
• The sheriff could request the information but no system at the county level to ensure this happens safely for workers. 
• No method for county agencies to communicate directly with pass holders. All communication is via employers.

The research team is holding local forums and events to disseminate these results directly to farm workers, two forums open to the public.

Recommendations:

• Recommending consolidating the AgPass application under one department (e.g. under Ag Commissioner) to make process more clear, streamlined, address concerns identified with signing up via the Sheriff's office (considering largely undocumented workforce)
• Support additional research: survey H2A workers inside evacuation zones, specific needs of indigenous language speakers in the county (current offerings only available in Eng/Spanish), understanding air pollutant exposures (increased monitoring), financial literacy needs (long-term planning in changing climate and extreme weather, likelihood this will only get worse)
• Health focused recommendations to SoCo BOS:
• Public Health and Health officials should be included in decisions to activate the Ag Pass, specifically tracking air quality and heat levels inside evacuation zones
• Increased air monitors across the county (hyper-local info needed in rural areas)
  
• Increase collaboration and support with Sonoma County Community Organizations Active in Disaster (COAD), 80 organizations across the county who have infrastructure to provider training and information to farm workers
• $$ support for health and safety training
• PPE to COAD that could be distributed BEFORE fire season in places that are comfortable
• Safety kids: N95, info about wildfire smoke, Cal-OSHA
• Training for employers and how to protect self and 
• Require sufficient stockpile of N95 for workers
• Increase hours of FQHCs across the county, expanded mobile health services, expanded monitoring 
• FQHC collecting farmworker employment
• Health focus recommendations for State of CA
• Update Cal-OSHA smoke standards (AQI >150, PPE needs to be available but not mandatory until AQI >500, no level which is considered unsafe to work)
• Need more monitoring of AQI levels during fire event
• Need requirements employers to communicate AQI levels
• Decrease barriers to reporting concerns to Cal OSHA
• Recommendation for Safety
• Use current active SoCo Alert system, require Ag Pass holders to sign up for these alerts, sign up all farm workers for these alerts
• Develop new alerts: e.g. Ag Pass activated, Deactivated, AQI levels
• Recommendations for economic improvements
• Interconnection of health/economic security
• Comprehensive disaster pay program; create meaningful choice for workers (e.g. hazard pay, disaster insurance, unemployment, paid sick leave)
• Enforcement of retaliation protection so workers don't lose job after choosing not to work for health and safety reasons

It is our duty as family physicians, particularly those of us working in the safety net, to pay attention to local policy and politic and to advocate for safer working conditions for our most vulnerable patients. Please help out where you can!

Caring for Incarcerated Patients (Lozada, 9/15/2020)

I have deep gratitude for a powerful Grand Rounds this week by Dr. Christina Lozada, on Caring for Incarcerated Patients.

Dr. Lozada presented statistics on the state of mass incarceration in this country, reflected on her personal and professional experience of caring for incarcerated patients during her training, and encouraged us to do better in caring for incarcerated patients.

The US has the highest incarceration rate of any industrialized nation in the world.

• 4.4% of the world's population, 22% of the world's prisoners
• 2.3 million incarcerated people in the US, 4.5 million on parole, and 3 million ex-convicts
• ~870/100,000 US citizens 
• 57% in state prisons, 27% local jails/prison, 9% federal prisons

Who are our jail patients? 

Disproportionately young people of color, poor people, mentally ill people, poor people

• 34% non-Hispanic Black, 24% Hispanic
• Black and Hispanic men are incarcerated at 5.1 and 1.4 x rate of whites
• Mean age 32.1 (jail), 35.6 (prison)
• 10% are Veterans, 12-17% were homeless in the year prior to incarceration
• More than half have less than a high school diploma

Females are the fastest growing population in jails and prisons

• Compared to men, incarcerated women have higher rates of chronic disease, substance use disorder, and mental illness. 
• Elevated rates of depression, PTSD and antisocial personality disorder
• Most incarcerated women have experienced childhood physical and/or sexual abuse
• 6-10% incarcerated women are pregnant

Mental health issues are important

• 25% of all inmates have a mental health diagnosis (even higher for women 30-62%)
• 70-75% have taken a psychotropic medication
• Depression, PTSD and substance use disorder all very common. PTSD associated with higher rates of risky behavior including prostitution, IVDU, substance abuse

Dr. Lozada invoked The 8th Amendment of The Bill of Rights (1791) and Supreme Court Case Estelle vs. Gamble (1976) as the two main pillars of federal law that protect prisoners and should ensure them adequate access to high quality health care. She also called us to review our very own Hippocratic Oath.

The 8th Amendment guarantees freedom from cruel and unusual punishment. Estelle vs. Gamble ensures: access to care (including hospitals and specialists), ordered care (i.e. ordered by a physician), medical care without bias to the incarcerated status, proper medical records, confidentiality, autonomy (right to refuse care). 

While the law guarantees provision of care for prisoners, it frequently falls short of an acceptable standard of care. This is because standards are vague and/or undefined. There are differences in budgets and policies across federal, state and local jurisdictions.

Three important ethical issues to take into account in caring for incarcerated patients that may not be well-respected or well understood.

• Privacy: incarcerated patients have the same right to privacy as any other patients (including HIPAA protections, having officers in the room during interviews/examinations, etc)
• Autonomy: incarcerated patients have the right to make their own medical decisions and the right to refuse medial care as well
• Surrogate decision maker: incarcerated patients have the same right to designate a surrogate decision maker in case they are unable to make their own medical decisions (the warden is NOT the default surrogate)

Correctional Care Companies (private, for-profit corporations that are contracted to provide health care inside jails and prisons) have inverse incentives for care delivery

• These companies get paid per patient per day: while they provide direct medical care (e.g. urgent care, chronic disease management), any care that requires transfer to hospital or specialist care comes out their profits
• There have been hundreds of lawsuits against them, multi-million dollar settlements
• Investigative reporters have uncovered hundreds of preventable deaths: including ignoring visible and growing cancerous tumors, placental abruption and chorioamnionitis leading to fetal demise, untreated DKA, undiagnosed ruptured duodenal ulcers, and more.

What do we know about how shackles in the hospital impacts care?

• inability to break falls when ambulating
• difficulty positioning during seizure management
• reduced mobility increasing the risk of thrombosis
• impede physical exam maneuvers
• prevent development of physician-patient trust
• reinforce stigma and judgement of incarcerated patients

Of note, The British Medical Association advocates that patients should be examined and treated without restraints or prison officials unless there is a security or escape risk

Patients who are incarcerated often experience their hospitalization as a negative one. They feel judged and mistreated. They feel unlistened to and mistrusted. Medical providers often refer to them as "jail patients" and describe them as unreliable, social outcasts, deserving of their medical ailments. Many of us do not have formal training on caring for incarcerated patients nor are we aware of laws and policies in place to ensure they receive good medical care.

What can WE do as medical providers caring for incarcerated patients?

• Ask prison officers to remove shackles in order to fully assess patient
• Ask prison officers to remove themselves from the room or stand at the doorway for more privacy
• Use accurate and stigma-free language that prioritizes individuals over characteristics
• Avoid defining people by the crime for which that are accused or convicted
• Ask if the patient consents to discussing PHI in front of law enforcement officials or asking officers to move out of hearing range
• Try to make a patient that is incarcerated feel more comfortable disclosing potentially legally detrimental elements of the medical history
• Become familiar with hospital policies related to the care of incarcerated patients
• Incorporate education of these topics into credentialing or regular hospital-based education meetings
• Take a tour of nearby jail medical facilities and put together a list of resources and contacts
• Ensure careful discharge planning as times of transition

And finally, consider the following thoughts:

Resources:

• AMEND: UCSF center designed to improve health inside correctional care facilities https://amend.us/providing-acute-care-for-seriously-ill-incarcerated-patients-in-the-community/
• American College of Emergency Physicians: https://www.acep.org/administration/resources/recognizing-the-needs-of-incarcerated-patients-in-the-emergency-department/
• AAFP Davis DM, Bello JK, Rottnek F. Care of Incarcerated Patients. Am Fam Physician. 2018;98(10):577-583.
• https://www.prisonpolicy.org/

Single Payer Health Care (Duncan, 9/9/2020)

Great thanks to Dr. Parker Duncan who gave a passionate presentation on Single Payer Health Care on his very own birthday! Dr. Duncan started with three foundational premises (which he called his disclosures). The beliefs that:

1) Health care is a human right.

2) The barriers to achieving single payer health care in the US are rooted in struggles with racism and inequality (not simply the money).

3) Thus, before health care for all, first make sure Black Lives Matter.

Dr. Duncan also introduced us to the three phases of A Road Map to Golden State Care,  a comprehensive plan written by the California Physician's Alliance (CaPA), which lays out strategic steps to get California to universal coverage and an equitable health care system. 

Phase 1 involves a focus on cost control measures (making the state the sole prescription drug/DME purchaser as well as creating an all payer claims database), establishing something called the Golden State Care and Trust Fund (GSCTF), and improving Medi-Cal, which is already California's largest insurer.

Phase II creates a Medi-Cal buy-in via Covered California (a public option) as well as all-payer rate setting via Golden State Care.

and

Phase III involves transitioning to a true GSCTF which includes a 95/5% mandate (that is 5% cap on administrative spending) vs. non-profit insurance managers

An info-graphic of the strategic plan is seen below. The road map, published in 2019, can be found here in its entirety. 

Dr. Duncan shared some of the current bills that have passed and/or are moving through CA legislature-- essentially incrementally changing our system. These include SB-104 (signed into law 7/2019), which expanded Medi-Cal to undocumented adults ages 19-25 "who are otherwise eligible for these benefits but for their immigration status", expanded pregnancy Medi-Cal for maternal mental health conditions, and established the founding of a Health CA for all Coalition.

There are other bills making their way through the CA Legislature including cost containment bills and additional bills to expand Medi-Cal to undocumented seniors. For more information on legislative issues. Dr Duncan recommends you go to this resource: Health Access, California's Health Consumer Advocacy Coalition

Also, consider signing up for daily emails with health policy updates here: PNHP Qote of the Day, written by Dr. Don McCanne. 

Another excellent health policy resource that is politically neutral and very well researched and reported is the Kaiser Family Foundation.