A Mobile Primary Care Clinic Mitigates an Early COVID-19 Outbreak Among Migrant Farmworkers in Iowa

ABSTRACT

Migrant and seasonal farmworkers are a vulnerable population with unique health and safety challenges related to the entire spectrum of the social determinants of health. These challenges place migrant and seasonal farmworkers at a disproportionate risk of infection and illness because of the COVID-19 pandemic. This report presents a case study of an early COVID-19 outbreak among migrant farmworkers in Iowa and describes the role that a nimble and responsive mobile federally qualified health center played in the successful mitigation and response to this outbreak. Early during the pandemic, the clinic adopted a new model of service delivery utilizing telemedicine primary care visits, followed by in-person visits when necessary. As the pandemic progressed, clinic staff strategized to provide increased pandemic-related support to agricultural employers and migrant farmworkers across the state. Emphasis was placed on on-site testing and education regarding social distancing, mask utilization, and hand washing. Eventually, as migrant workers were infected and became symptomatic, more complex mitigation strategies such as isolation, quarantine, and clinical follow-up were also implemented. This report describes how a mobile primary care clinic developed a pandemic responsive model to provide successful mitigation of an early COVID-19 outbreak among essential and highly vulnerable migrant farmworkers.

KEYWORDS:

• Migrant health
• Covid-19
• Farmworkers;
• Health disparities

Introduction

As the Iowa 2020 agricultural season began, there were an increasing number of reports in the media alerting the American public to the disproportionate effect that the COVID-19 pandemic was having on the health and wellbeing of the migrant farmworker population across the United States.^1,2 Like other aggregate groups that include racial or ethnic minorities,³ migrant farmworkers are among those populations that have been most severely affected by the COVID-19 pandemic.⁴ Attention to this previously invisible group of workers was heightened as the public became more aware of the essential function they serve to produce the nation’s food supply.⁵

The major Iowa agricultural production products are corn,⁶ soybeans,⁷ hogs, eggs,⁸ and meat processing,⁹ and the state hosts approximately 7000 migrant and seasonal farmworkers each year.¹⁰ As migrant workers travel to Iowa primarily from Texas or Mexico, they are often placed in crowded, poorly ventilated buses.¹¹ While working on Iowa farms, workers usually reside in run-down congregate living quarters, travel to the fields in multi-person vehicles, and eat meals in communal settings.¹² Historically, there has been little workplace support for healthcare and positive health outcomes among these vulnerable workers.¹³ Recently, social distancing while working and living on Iowa farms, has not been possible.¹⁴ This singular reality predicted the disproportionate risk of COVID-19 infection and illness experienced by migrant farmworkers in Iowa and across the nation.¹⁵

Practice adaptation of a mobile primary care clinic

Proteus Inc. is a Health Resources and Services Administration (HRSA)-funded 501(c)3 nonprofit, federally qualified community health center that has worked with migrant and seasonal farmworkers for the past 41 years. Proteus has a long history of providing multifaceted support for farmworker families that simultaneously addresses challenges within multiple social determinants of health.¹⁶ In Iowa, their providers offer mobile primary healthcare to approximately 1500 migrant and seasonal farm workers each year, regardless of insurance or immigration status. In addition, Proteus operates in a tri-state region (Iowa, Nebraska, and Indiana) to provide thousands of farmworkers with health and safety training, as well as education assistance and job training.¹⁷ They also provide workers with basic sustenance support including access to food and cash-based financial support.

As a known and trusted partner in the agricultural migrant community, Proteus took the early lead for pandemic response for growers and migrant workers across the state. Typically, at the beginning of the migrant farmworker season, bilingual health care staff conduct large health clinic registration events for migrant workers upon arrival at their work sites, as well as deliver didactic safety content on heat stress and pesticide use. In 2020 a bilingual virtual town hall meeting was conducted with workers to provide education around COVID-19 testing, social distancing, and other important prevention measures. In a typical year, after registration and education, registered migrant farmworkers receive periodic primary care visits via mobile clinic services throughout their residential time in Iowa. Early in the pandemic, providers proactively pivoted their model of care delivery and adopted a telemedicine option. To maximize social distancing and protect both farmworker and healthcare staff, they conducted telephone visits in the evening, followed by in-person follow-up the next day when necessary. While federal guidance regarding personal protection for healthcare workers and public was evolving, Proteus staff and patients always utilized recommended personal protective equipment during in person encounters.

Most farm owners and managers, whose workers we serve, began the 2020 agricultural season with knowledge gaps and confusion over Centers for Disease Control (CDC) guidelines, and financial challenges related to the implementation of COVID-19 infection prevention strategies in the farm fields¹⁸ and within worker living quarters.¹⁹ Local, state, and national public health organizations were faced with a multitude of challenges related to preparedness and response to COVID-19, and unfortunately, early preparation and response for the migrant workforce was not prioritized among their operations. Given the initial dearth of local and state support, Proteus assumed early leadership for COVID-19 preparedness and response for farm employers and their migrant and seasonal farmworkers throughout the agricultural season across Iowa. As the media began reporting farmworker infections in warmer states during the first few weeks of 2020, Proteus staff reached out to farm owners and managers to offer either in-person or virtual education about protecting the health and safety of workers during the pandemic. This effort has focused on widespread testing of workers upon arrival to Iowa. It also focused on mask distribution, so that to date, over 15,000 masks have been distributed to farmworkers. Further, Proteus has been providing guidance and coordination of support for employers when isolation or quarantine of COVID-19 positive or exposed workers is necessary. Farmworkers who are isolated due to infection are provided regular clinical follow-up at their living quarters, and hospital referrals are made for symptomatic workers when necessary. In addition to clinical follow up, workers receive sustenance support, including food, water, and supplies, such as soap, towels, and hand sanitizer. Enabled by the CARES Act, a federal 2.2 trillion-dollar economic stimulus bill passed in response to the pandemic, Proteus staff continue to work with farm employers to provide health and safety support during the ongoing pandemic.

Over time, Proteus established a close collaboration with the Iowa Department of Health, Iowa Workforce Development, State Hygienic Lab, Homeland Security, and the Iowa Governor’s Office, to provide testing of as many farmworkers as possible. This testing was performed through group testing events upon arrival to Iowa, usually on employer property. Over the course of 6 months during the agricultural season, the Iowa Department of Public Health performed 678 tests, and Proteus performed over 2000 tests in collaboration with farmworker employers. In addition, Proteus performed test during primary care clinic sites for symptomatic or asymptomatic exposed workers.

Case study

Due to longstanding relationships with Iowa growers and farmworkers across the state, Proteus providers are usually the first health care professionals to become aware of an illness or infectious disease outbreak within a migrant or seasonal farmworker community. Therefore, it was not surprising when providers discovered an early outbreak of COVID-19 among workers on one small Iowa farm. This small rural operation depends upon migrant and local labor each summer. The migrant workers form a crew that works, eats, and socializes together. In addition, the workers reside in trailers that house four to six workers per residence.

While living in Iowa, many of the migrant workers on this farm receive primary care services from Proteus. In early spring, 2 weeks after arrival in Iowa, one migrant worker received a telehealth evaluation for wrist pain. During routine screening about possible COVID-19 symptoms, the worker reported a cough, but denied all other symptoms. The following day, health aides traveled to the farm and performed a nasopharyngeal swab for polymerase chain reaction testing. Considering the inability of workers to practice consistent social distancing, Proteus arranged for the worker to be isolated in a local hotel immediately after testing. Soon after receiving notification of the positive test result, Proteus recommended testing the remaining 65 workers, 21 (32%) of whom were Latinx. The employer was receptive and enabled additional testing.

Among the Latinx workers, a total of nine workers tested positive for COVID-19, with a 41% positivity rate. Except for the first worker tested, all positive individuals were asymptomatic. There were no positive test results among the remaining non-Latinx workers. Of the positive Latinx workers, 21 (95%) were male, and 20 (91%) of the Latinx workers only spoke Spanish. All the Latinx workers originated from Texas prior to arrival in Iowa.

Immediately after testing, all workers were housed in individual rooms, including hotel accommodations. All workers with positive test results remained in isolation for a total of 10 days, according to CDC guidance.²⁰ Workers with negative test results were released to lower density housing, with two people per trailer, and released to work. Daily check-in calls to assess the workers’ health status were conducted while they remained in isolation. Proteus provided provisions such as meals and personal hygiene products while housed in hotels. All workers with positive test results successfully returned to work after the 10-day isolation period. No other outbreaks were experienced among migrant or local workers on this farm for the rest of the agricultural growing season. During the course of this outbreak, these mitigation activities monopolized the efforts of the small Proteus staff for 2 weeks, until all workers were successfully released to work with stable health status.

The successful outcome of this COVID-19 outbreak was enabled by the Proteus model of care, which is dependent upon a mobile and bilingual staff as well as an administration that allows for rapid and nimble response to healthcare urgencies. In this case, Proteus was further enabled by rapid decision-making capability that allowed timely disbursement of financial resources from CARES Act funding to support testing, quarantine, and isolation, as well as food and personal hygiene products. Placing workers in quarantine and isolation was frightening to most of the workers; however, counseling by staff who speak Spanish and are of a similar ethnic background was a crucial factor in engendering the trust and cooperation of the workers during a time of great uncertainty. Similarly, a trusted relationship between the employer and Proteus staff, developed over many years, enabled communication with the employer, who was receptive to close worker follow-up throughout the pandemic and the remainder of the agricultural season.

Discussion

While we were alarmed by the high COVID-19 infection rate among the Latinx migrant farmworkers in this outbreak, we were not surprised. There were early anecdotal reports in the lay media from across the country of disproportionately high COVID-19 infection rates among migrant farmworkers.²¹ It bears noting that by late summer 2020, guidance was appearing in the lay and scientific literature that suggested best practices for migrant workers, including testing on arrival and quarantine or isolation on arrival, prior to release in to work.^18,22 While these practices were encouraged by Proteus throughout the season at various Iowa farm sites, there was initially no county or state process in place to screen or test farmworkers workers for infection. To date, neither state nor county support for quarantine or isolation housing has been planned for Iowa. In the case of this reported early season outbreak, it is indeed fortunate that the first and only symptomatic worker was identified on a Proteus symptom screen during a primary care visit complaining of wrist pain, thus enabling a prompt response by Proteus staff.

Since this early outbreak, there have been increasing data in the scientific literature that confirms the greater burden of disease experienced by Latinx populations across the country.^23,24 We have known that many Latinx populations, including migrant and seasonal farmworkers, experience many chronic health conditions,²⁵ which may lead to more serious illness as a result of COVID-19 infection. However, comorbidity due to these chronic health conditions does not fully account for the disproportionate burden of disease many Latinx populations are experiencing during this pandemic.²⁶ Migrant and seasonal farmworkers are among our most vulnerable workers due to factors related to the entire spectrum of social and structural determinants of health. Due to the migratory nature of their work, sheltering at home or social distancing is difficult or not possible for many workers. The workers often live in inadequately maintained, poorly ventilated,¹³ and crowded congregate housing,²⁷ where access to optimal hygiene resources is usually limited. Fear of pay cuts, job loss,²⁸ and deportation²⁹ make migrant workers reluctant to report symptoms,³⁰ making infection detection through screening and treatment a unique challenge. Racist narratives and stigmatization may further deter these essential workers from reporting symptoms when they feel unwell.

Implications for future practice and policy

While this case study reports the experience of a small group of workers on a small Iowa farm, it reflects the larger challenges that were already unfolding across the country and foreshadowed the challenges to come for the rest of Iowa. One year later, the lack of adequate public health preparedness and response during the COVID-19 pandemic continues to place our vulnerable farmworkers at a disproportionate risk of infection and disease. To date, approximately 125,000 farmworkers have been infected by COVID-19 across the country,³¹ and thus far, only 14 states have implemented farmworker protections during the pandemic. Unfortunately, despite the reality that the Iowa farm economy depends on migrant and seasonal farmworkers, Iowa is still not among the small group of states that have committed to supporting the migrant and seasonal farmworker population during the pandemic with specific state policies.³¹ Attempts at federal legislation is similarly difficult to realize, as exemplified by delays in passing the Fairness for Farm Workers Act, H.R.1080, which supports overtime pay for agricultural workers.³² While specific federal guidelines now exist,³³ the health and safety of farmworkers falls to state and local health agencies, which have become increasingly overwhelmed and under-resourced as the pandemic has evolved. Without increased logistical and financial assistance, as well as policies that legislate standards and expectations, following CDC guidelines and other best practices will remain in the realm of the “best case scenario” rather than become a day-to-day reality for our most vulnerable workers. The downstream effects on both local healthcare systems and the farm economy will continue to present an unsustainable strain.³⁴

The migrant and seasonal farmworker experience during the COVID-19 pandemic is a stark reminder of the healthcare disparities that we know have always existed. It is imperative that we as a nation now reflect upon the structural and social forces that perpetuate inequalities among ethnic minorities and place our most vulnerable populations at risk.³⁵ The pandemic has made our national reality undeniably clear. Health disparities make our entire population vulnerable, as the health and economic well-being of our essential workers and our nation are forever intertwined.

Acknowledgments

We would like to thank Daniel Hoffmann-Zinnel, EdD, Caroline Johnson, ARNP, and all Proteus staff for their tireless support of migrant and seasonal farmworkers.

Disclosure statement

Authors Corwin and Sinnwell provide part-time primary care services at Proteus.