Article By: Aisling Carroll
Meeting in Fields and Parking Lots
Alongside some of the highest-producing fields in the world, Dr. Erika Romero, a medical resident at Natividad Medical Center used to a gleaming hospital floor underfoot, stood on an outdoor gravel parking lot in Monterey County’s Salinas Valley.
She spoke with a group of farmworkers who had stopped cutting cauliflower and bagging lettuce to talk about Covid-19. This was Natividad’s first coronavirus outreach “charlas” (chat).
Yes, the coronavirus was real. No, a sore throat might not just be a sign of a cold; it could be Covid-19. Yes, it is safe to go to the hospital.
But none of these workers knew anyone who was sick. Some of them were skeptical. Rumors abounded. It was early April, before the CDC recommended wearing masks, before doctors wore spacesuits on the news, before the County reported more than a handful of Covid-19 infections.
Dr. Romero and her colleagues, however, knew Covid-19 was trying to take hold.
They also knew that these farmworkers, who were unable to shelter-in-place because of their essential work, would suffer disproportionately. The numbers and suffering could be an unthinkable catastrophe. Some 55,000 lived or were temporarily working in Monterey County for the harvest season. These agricultural workers make up many of the patients at Natividad, which is the only public health care system in the region and the area’s only level two trauma center.
Because the average California farmworker makes $20,500 per year, they are subject to a multitude of virus-friendly situations that make them acutely vulnerable to Covid-19. For example, many can’t socially distance because they can’t afford a car that would allow them to drive to work solo. So instead, they often carpool or rely on employer vans, and sit inches from each other.
When they arrive at the fields and packing houses, it’s difficult for them to physically separate from their two-dozen strong crew members and efficiently work the land.
And at the end of their day, most farmworkers return to a crowded home. Due to the high cost of housing in California and their low pay, many share rooms with other families and multiple generations of their own.
Farmworkers are frequently in situations where they must move, stand or sit next to someone, which significantly increases their coronavirus risk.
They also often lack access to health care and may have underlying health conditions (e.g., respiratory issues) due to the nature of their work, which can make them more susceptible to the disease. And many cannot get coverage through Medi-Cal because of their immigration status. Others don’t seek medical attention because of the fear of deportation, the cost of care or lost wages if they miss work.
These circumstances put their health and lives at greater risk, and could compromise the nation’s food supply and any progress the community makes against the pandemic at risk.
Because the average California farmworker makes $20,500 per year, they are subject to a multitude of virus-friendly situations that make them acutely vulnerable to Covid-19.
The First “Charlas” (Chats)
Working furiously to cut the coronavirus off at the pass in February, Natividad started blanketing the farmworker community with Covid-19 information (public service announcements, newsletters, hotlines and Facebook posts) in Spanish, and sometimes in indigenous languages. Although more than 90 percent of California farmworkers are Latinx, thousands of farmworkers in Monterey County speak an indigenous language from Mexico, such as Triqui or Mixteco, and little to no Spanish.
The hospital also secured 40,000 high-quality masks for farmworkers from an apron maker, thanks to one of its resident’s ingenuity. And Natividad Foundation later secured funding for an additional 5,000 reusable masks for farmworkers.
Still, Natividad was well aware of the many barriers farmworkers faced to obtaining information and resources.
“Not everyone is going to have a smartphone they can afford right now. Not everyone is going to have Wi-Fi,” said Hillary Fish, Natividad’s director of marketing and community relations. She also couldn’t bank on them hearing a radio ad.
So Natividad’s medical residents and nurses, along with those of other area hospitals, went directly to speak with farmworkers in the fields and packing houses.
“I didn’t want to sit there and give a list of data,” said Dr. Romero. “I wanted to have a conversation.”
She guided several of Natividad’s outreach efforts (charlas), which ran from April through June and reached thousands of farmworkers.
During the talks, Dr. Romero was transparent about what the medical community knew at that moment in time and what it did not about Covid-19, which helped build trust. With many doubting what they could not see in the pandemic’s early days, she shared firsthand accounts of how the disease was not limited to the old and compromised.
“I’m seeing very young men who are in the ICU,” she told farmworkers during the charlas. These harrowing stories landed. Farmworkers grew concerned about the physical and financial impact Covid-19 might have on their families. They also recognized that Dr. Romero, a daughter of Salvadoran immigrants, was highly credible.
“I can relate to a lot of their experiences and understand their plights,” she said.
Then she flipped the script and turned the charlas over to the farmworkers: What were their biggest obstacles to staying safe? What were their greatest concerns? What solutions would work best in their environment?
The farmworkers designed and developed new ways of protecting themselves. For example, they created smaller cohorts that would carpool, work and eat together. That way, if one person contracted Covid-19, the virus might be contained to fewer people. Their strategy might also prevent the whole facility from shutting down and laying off workers, which was a looming worry.
“I didn’t want to sit there and give a list of data. I wanted to have a conversation.”
– Dr. Romero
Medics as Mediators
But before the farmworkers started brainstorming these strategies, they had to first feel safe enough to openly share ideas and concerns (e.g., a lack of PPE) without any fear of retribution from the foremen (“mayordormas”) who also participated in the charlas.
The workers and mayordormas “don’t always have the best of relationships,” said Dr. Romero. Mistrust can exist on both sides.
However, each group trusted Natividad’s clinicians. They had a reputation – decades in the making – of effectively caring for the community with no other agenda than promoting health.
As such, Dr. Romero and her colleagues were in the unique position of helping the two groups agree on coronavirus-related steps to take with “the ultimate goal of protecting everyone: the mayordormas, the workers, the infrastructure,” she said.
These mediations enabled the farmworkers and mayordormas to generate and agree upon, and implement specific solutions, including social distancing in employer vans and staggering breaks.
Dr. Romero and colleagues also collaborated on personalized plans to stop the spread.
“What can I do to not give this to my daughter with special needs?” one farmworker asked Dr. Romero as a charlas wrapped up.
The worker told Dr. Romero that she was scared. She had to work and wanted to help her team in the fields, but she didn’t want her daughter in harm’s way.
“So much of this is not about them but about their families,” said Dr. Romero.
The farmworker lived in a one-room home with another family, had diabetes and did not have health care. As she described her circumstances, she and Dr. Romero created a plan of what the worker would do as soon as she returned home, such as leaving her shoes in a designated area outside, as well as who she might call to access a doctor.
Taking Covid-19 precautions was only one part of what was discussed during the charlas. The other was what farmworkers would do if they had symptoms, had been exposed or tested positive, and how they could protect themselves physically, financially and emotionally in these situations.
Providing handouts in Spanish, Natividad residents and nurses discussed free testing and medical care, free housing for quarantining and state disability insurance, regardless of immigration status. Their objective was to discourage workers from showing up to work sick and spreading the virus.
“So much of this is not about them but about their families.”
– Dr. Romero
An Unusual Partnership
What may have mattered most about the charlas was the timing.
“We went into action early on,” said Dr. Romero. “And because of that, I think we saved so many lives.”
The key reason why Natividad Medical Center’s residents and nurses, as well as clinicians from other hospitals, were able to hold charlas-after-charlas in rapid-fire succession during the early days of the pandemic was because of an unusual partnership brokered by the hospital.
In March, a group of farmworker advocates, academics, county officials and hospitals – including Natividad – formed to protect farmworkers from Covid-19.
Called the Monterey County Coalition of Agriculture (MC-COA), the group wanted to help deploy clinicians from local hospitals to dozens of farms and packing houses to provide outreach education.
The roadblock was that no one around the virtual table had the resources or time to do the heavy lifting of organizing the logistics for each facility visit. It would take weeks.
Natividad knew one organization that might solve this problem: The Growers-Shipper Association (GSA). The hitch was that GSA represented the farmers and facility operators who many coalition members often disagreed with.
“They don’t always see eye-to-eye,” said Natividad’s Hillary Fish.
But keeping the big picture of putting critical information and masks into farmworkers’ hands ASAP was front of Fish’s mind. “Bringing the groups together was challenging at first, but we all had a common goal of protecting high-risk members of our community,” she said. “Fortunately, everyone wanted to do the right thing.”
And the right thing was everyone agreeing that GSA would get the word out to its 300 farm and facility members and others that medics wanted to conduct in-person education to farmworkers about Covid-19.
By taking the reins (and a risk) to involve other groups like GSA that could help, Natividad was able to greatly accelerate the speed at which life-saving information was shared, prevention measures implemented and behaviors changed.
“We went into action early on. And because of that, I think we saved so many lives.”
– Dr. Romero
A One-Two Punch
Even with these efforts, however, the Covid-19 surges still came. Starting in the summer and rising at alarming levels through the fall and winter, they have disproportionately affected farmworkers. According to a study from the California Institute for Rural Studies, Monterey County farmworkers were three times more likely to contract COVID-19 than those working in non-agricultural industries during the summer of 2020.
Unsurprisingly, Natividad’s work has not let up. Clinicians have continued to push hard, using what they’ve learned from farmworkers at the charlas to better meet worker needs.
Currently, the hospital’s doctors, nurses and communications team are working on a community-driven vaccine education campaign with farmworker organizations like GSA. MC-COA recently joined forces with a new organization in Monterey County called the COVID-19 Collaborative. Fish and several doctors from Natividad are active leaders of the group, which has further improved the hospital’s pandemic response.
The vaccine effort could not be more critical. Farmworkers who contract Covid-19 are more likely to become critically ill or die because of their often side-by-side working and living conditions, a lack of access to health care and a higher prevalence of chronic diseases.
But only half of Monterey County’s farmworkers reported they were “extremely likely” to get vaccinated, according to a December 2020 study led by researchers at the UC Berkeley School of Public Health. Natividad is leaning on the trust it has built up through its in-the-fields education campaign and continuing its listen-first approach to change minds.
“It has to be collaborative or it won’t work,” said Dr. Romero.
“It has to be collaborative or it won’t work .”
– Dr. Romero
This blog is part of a series funded by the California Health Care Foundation.